| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,787 |
741 |
$92K |
| D1120 |
Prophylaxis - child |
2,039 |
2,012 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,625 |
2,588 |
$75K |
| D1110 |
Prophylaxis - adult |
1,088 |
1,073 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
416 |
246 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,576 |
1,547 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,253 |
1,241 |
$29K |
| D0330 |
Panoramic radiographic image |
375 |
370 |
$15K |
| D0272 |
Bitewings - two radiographic images |
832 |
826 |
$12K |
| D0274 |
Bitewings - four radiographic images |
542 |
539 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
205 |
$10K |
| D1330 |
|
1,290 |
1,276 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
40 |
$360.00 |