| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,713 |
855 |
$88K |
| D1120 |
Prophylaxis - child |
2,264 |
2,145 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,591 |
2,472 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,284 |
1,209 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
719 |
687 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,189 |
834 |
$19K |
| D0272 |
Bitewings - two radiographic images |
856 |
818 |
$16K |
| D0274 |
Bitewings - four radiographic images |
604 |
569 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
207 |
122 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
924 |
895 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
151 |
96 |
$11K |
| D1110 |
Prophylaxis - adult |
82 |
82 |
$3K |
| D1354 |
|
235 |
67 |
$3K |