| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,372 |
201 |
$25K |
| D1120 |
Prophylaxis - child |
981 |
897 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
275 |
178 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,425 |
1,307 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,013 |
928 |
$14K |
| D1110 |
Prophylaxis - adult |
373 |
343 |
$11K |
| D0330 |
Panoramic radiographic image |
233 |
208 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
383 |
351 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
192 |
112 |
$8K |
| D0272 |
Bitewings - two radiographic images |
304 |
270 |
$4K |
| D0274 |
Bitewings - four radiographic images |
192 |
175 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$388.73 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
20 |
$216.35 |