| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,224 |
263 |
$68K |
| D1110 |
Prophylaxis - adult |
692 |
690 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,202 |
1,202 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
215 |
88 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
170 |
168 |
$12K |
| D1120 |
Prophylaxis - child |
277 |
276 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
220 |
$11K |
| D1206 |
Topical application of fluoride varnish |
383 |
383 |
$10K |
| D0274 |
Bitewings - four radiographic images |
270 |
270 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
512 |
510 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
38 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
134 |
134 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
310 |
307 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
47 |
$2K |