| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
988 |
676 |
$101K |
| D1120 |
Prophylaxis - child |
1,575 |
1,575 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
1,719 |
1,719 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,572 |
1,572 |
$43K |
| D4341 |
|
217 |
118 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
307 |
244 |
$24K |
| D0274 |
Bitewings - four radiographic images |
920 |
920 |
$18K |
| D1110 |
Prophylaxis - adult |
319 |
319 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
487 |
487 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,376 |
1,372 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
122 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,207 |
1,207 |
$7K |
| D0272 |
Bitewings - two radiographic images |
318 |
318 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
163 |
162 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
27 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
135 |
133 |
$2K |