| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
34,426 |
6,992 |
$700K |
| D1206 |
Topical application of fluoride varnish |
11,677 |
11,296 |
$349K |
| D0190 |
|
11,312 |
10,965 |
$152K |
| D1120 |
Prophylaxis - child |
1,576 |
1,486 |
$59K |
| D9999 |
Unspecified adjunctive procedure, by report |
779 |
779 |
$26K |
| D1353 |
|
1,180 |
390 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
511 |
481 |
$15K |
| D9992 |
|
776 |
671 |
$13K |
| D0603 |
|
2,730 |
2,666 |
$12K |
| D0330 |
Panoramic radiographic image |
303 |
290 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
103 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
352 |
342 |
$8K |
| D0602 |
|
1,571 |
1,517 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
531 |
505 |
$6K |
| D0272 |
Bitewings - two radiographic images |
321 |
307 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
717 |
588 |
$4K |
| D1354 |
|
344 |
78 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
43 |
$3K |
| D0274 |
Bitewings - four radiographic images |
115 |
100 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
15 |
$1K |
| D1355 |
|
60 |
15 |
$725.70 |
| D0999 |
Unspecified diagnostic procedure, by report |
13 |
13 |
$390.00 |