| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
697 |
139 |
$16K |
| D1110 |
Prophylaxis - adult |
486 |
453 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
704 |
662 |
$14K |
| D1120 |
Prophylaxis - child |
390 |
375 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
93 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
161 |
157 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
37 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
116 |
105 |
$2K |