| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
783 |
198 |
$20K |
| D1120 |
Prophylaxis - child |
397 |
394 |
$12K |
| D1206 |
Topical application of fluoride varnish |
473 |
466 |
$8K |
| D0272 |
Bitewings - two radiographic images |
330 |
326 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
249 |
242 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
212 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
28 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
29 |
$2K |
| D1110 |
Prophylaxis - adult |
60 |
58 |
$2K |
| D0274 |
Bitewings - four radiographic images |
69 |
66 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
220 |
209 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
213 |
211 |
$2K |
| D1354 |
|
169 |
62 |
$1K |