| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,394 |
448 |
$108K |
| D1110 |
Prophylaxis - adult |
957 |
955 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,266 |
1,264 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
119 |
$27K |
| D1206 |
Topical application of fluoride varnish |
964 |
964 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
376 |
376 |
$23K |
| D1120 |
Prophylaxis - child |
506 |
506 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
898 |
890 |
$16K |
| D0274 |
Bitewings - four radiographic images |
386 |
386 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
157 |
157 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
700 |
671 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
25 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
46 |
$3K |