| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,477 |
866 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,886 |
2,804 |
$65K |
| D0274 |
Bitewings - four radiographic images |
2,811 |
2,726 |
$55K |
| D1110 |
Prophylaxis - adult |
1,889 |
1,832 |
$46K |
| D1120 |
Prophylaxis - child |
2,196 |
2,130 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,213 |
1,176 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,401 |
3,295 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
556 |
303 |
$26K |
| D0330 |
Panoramic radiographic image |
918 |
913 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
447 |
407 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
106 |
$10K |
| D0272 |
Bitewings - two radiographic images |
611 |
596 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
22 |
15 |
$635.00 |
| D1206 |
Topical application of fluoride varnish |
58 |
58 |
$456.00 |