| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
10,004 |
1,561 |
$240K |
| D1110 |
Prophylaxis - adult |
2,068 |
2,026 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,823 |
2,771 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,021 |
1,976 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,910 |
2,865 |
$52K |
| D1120 |
Prophylaxis - child |
1,359 |
1,329 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
502 |
264 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,876 |
2,734 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,205 |
2,608 |
$32K |
| D0330 |
Panoramic radiographic image |
468 |
455 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
678 |
663 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
285 |
271 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
69 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
15 |
$2K |