| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
22,246 |
1,582 |
$544K |
| D1110 |
Prophylaxis - adult |
4,364 |
4,250 |
$189K |
| D0274 |
Bitewings - four radiographic images |
4,651 |
4,544 |
$145K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,188 |
6,850 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
5,715 |
5,588 |
$127K |
| D0220 |
Intraoral - periapical first radiographic image |
6,593 |
6,247 |
$85K |
| D1120 |
Prophylaxis - child |
3,106 |
3,027 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,695 |
3,868 |
$49K |
| D0140 |
Limited oral evaluation - problem focused |
1,584 |
1,514 |
$47K |
| D0272 |
Bitewings - two radiographic images |
2,021 |
1,967 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,224 |
1,173 |
$36K |
| D0330 |
Panoramic radiographic image |
412 |
402 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
77 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
14 |
$3K |