| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,145 |
237 |
$28K |
| D1110 |
Prophylaxis - adult |
520 |
519 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
854 |
850 |
$17K |
| D1120 |
Prophylaxis - child |
489 |
488 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
702 |
700 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
151 |
77 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
93 |
65 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
281 |
279 |
$5K |
| D0274 |
Bitewings - four radiographic images |
200 |
200 |
$5K |
| D0330 |
Panoramic radiographic image |
119 |
119 |
$4K |
| D1330 |
|
494 |
491 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
50 |
$409.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
27 |
$229.36 |