| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
6,582 |
1,025 |
$359K |
| D1120 |
Prophylaxis - child |
1,506 |
1,494 |
$60K |
| D1351 |
Sealant - per tooth |
1,902 |
532 |
$54K |
| D1206 |
Topical application of fluoride varnish |
1,675 |
1,661 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
904 |
901 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
88 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
84 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
479 |
469 |
$17K |
| D0272 |
Bitewings - two radiographic images |
508 |
497 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
614 |
600 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
900 |
508 |
$10K |
| D1110 |
Prophylaxis - adult |
161 |
159 |
$10K |
| D0274 |
Bitewings - four radiographic images |
176 |
173 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
71 |
71 |
$1K |