| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,194 |
1,743 |
$106K |
| D1120 |
Prophylaxis - child |
3,716 |
3,607 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
2,770 |
2,691 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,624 |
1,562 |
$55K |
| D1206 |
Topical application of fluoride varnish |
4,271 |
4,136 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
718 |
476 |
$43K |
| D0272 |
Bitewings - two radiographic images |
2,516 |
2,440 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,330 |
1,584 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,140 |
1,096 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,707 |
1,639 |
$15K |
| D1110 |
Prophylaxis - adult |
566 |
541 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
314 |
225 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
65 |
49 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
214 |
184 |
$2K |