| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,185 |
481 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
534 |
263 |
$64K |
| D1110 |
Prophylaxis - adult |
1,051 |
1,038 |
$61K |
| D1120 |
Prophylaxis - child |
1,386 |
1,372 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,897 |
1,874 |
$55K |
| D1206 |
Topical application of fluoride varnish |
1,808 |
1,782 |
$45K |
| D0330 |
Panoramic radiographic image |
599 |
591 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,020 |
1,004 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
342 |
338 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
680 |
677 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
71 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
24 |
$7K |
| D1330 |
|
972 |
955 |
$6K |
| D0272 |
Bitewings - two radiographic images |
300 |
295 |
$4K |