| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
7,343 |
1,977 |
$123K |
| D1120 |
Prophylaxis - child |
5,320 |
5,169 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,673 |
2,570 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
3,554 |
3,480 |
$74K |
| D1206 |
Topical application of fluoride varnish |
5,744 |
5,589 |
$68K |
| D0272 |
Bitewings - two radiographic images |
3,832 |
3,739 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
712 |
467 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,793 |
2,917 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
3,086 |
2,980 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,092 |
1,052 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
374 |
260 |
$19K |
| D1110 |
Prophylaxis - adult |
644 |
637 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
274 |
231 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
64 |
$547.00 |