| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,964 |
1,265 |
$104K |
| D1120 |
Prophylaxis - child |
2,562 |
2,559 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
2,588 |
2,585 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
594 |
378 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,187 |
2,184 |
$22K |
| D0330 |
Panoramic radiographic image |
573 |
572 |
$17K |
| D0273 |
|
965 |
965 |
$11K |
| D0603 |
|
835 |
834 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
108 |
$8K |
| D0602 |
|
640 |
638 |
$6K |
| D1206 |
Topical application of fluoride varnish |
717 |
717 |
$6K |
| D1110 |
Prophylaxis - adult |
148 |
148 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
26 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$667.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$86.25 |