| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
7,299 |
1,021 |
$181K |
| D1110 |
Prophylaxis - adult |
1,251 |
1,172 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,224 |
2,076 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,446 |
1,346 |
$42K |
| D1120 |
Prophylaxis - child |
1,142 |
1,063 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,567 |
1,474 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
441 |
414 |
$7K |
| D0330 |
Panoramic radiographic image |
123 |
112 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
37 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
59 |
$2K |