| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
2,384 |
665 |
$47K |
| D0251 |
|
1,243 |
1,236 |
$32K |
| D1120 |
Prophylaxis - child |
876 |
873 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,197 |
1,191 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,150 |
1,143 |
$23K |
| D1351 |
Sealant - per tooth |
1,033 |
207 |
$20K |
| D1110 |
Prophylaxis - adult |
169 |
168 |
$6K |
| D0603 |
|
715 |
705 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$800.00 |
| D0250 |
|
61 |
61 |
$610.00 |
| D0602 |
|
13 |
13 |
$100.00 |