| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,692 |
845 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
730 |
403 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
813 |
436 |
$42K |
| D1120 |
Prophylaxis - child |
1,697 |
1,682 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
870 |
864 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,140 |
1,121 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,220 |
1,211 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,171 |
1,166 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
144 |
101 |
$6K |
| D1110 |
Prophylaxis - adult |
231 |
226 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
466 |
459 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
135 |
133 |
$3K |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$999.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$900.00 |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
78 |
$716.00 |