| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
8,209 |
995 |
$204K |
| D1120 |
Prophylaxis - child |
5,271 |
3,932 |
$114K |
| D0210 |
Intraoral - complete series of radiographic images |
1,632 |
1,207 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,336 |
2,227 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,680 |
1,508 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,463 |
3,151 |
$49K |
| D0140 |
Limited oral evaluation - problem focused |
1,438 |
1,038 |
$39K |
| D0272 |
Bitewings - two radiographic images |
2,565 |
1,792 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
756 |
196 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
399 |
163 |
$17K |
| D1206 |
Topical application of fluoride varnish |
575 |
569 |
$16K |
| D0330 |
Panoramic radiographic image |
316 |
268 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
146 |
58 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
880 |
671 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
14 |
$143.96 |