| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
7,069 |
1,109 |
$163K |
| D1110 |
Prophylaxis - adult |
2,243 |
2,046 |
$85K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,224 |
3,851 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
3,313 |
3,009 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
988 |
425 |
$59K |
| D1120 |
Prophylaxis - child |
1,984 |
1,837 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,451 |
1,312 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
612 |
292 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
287 |
245 |
$7K |
| D0272 |
Bitewings - two radiographic images |
213 |
196 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
216 |
160 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
73 |
56 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$714.48 |