| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,144 |
222 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
493 |
275 |
$63K |
| D0330 |
Panoramic radiographic image |
889 |
871 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,693 |
1,677 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
638 |
627 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
368 |
230 |
$38K |
| D1206 |
Topical application of fluoride varnish |
2,116 |
2,084 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,085 |
1,069 |
$34K |
| D1120 |
Prophylaxis - child |
862 |
848 |
$27K |
| D1110 |
Prophylaxis - adult |
497 |
493 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,165 |
524 |
$14K |
| D1320 |
|
672 |
653 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
724 |
698 |
$12K |
| D1330 |
|
484 |
472 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |