| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
9,465 |
4,481 |
$566K |
| D1120 |
Prophylaxis - child |
12,926 |
12,925 |
$531K |
| D0120 |
Periodic oral evaluation - established patient |
12,630 |
12,629 |
$366K |
| D1206 |
Topical application of fluoride varnish |
12,934 |
12,933 |
$337K |
| D1354 |
|
2,236 |
1,234 |
$52K |
| D0601 |
|
6,081 |
6,080 |
$51K |
| D0602 |
|
3,937 |
3,937 |
$33K |
| D0603 |
|
2,958 |
2,958 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
247 |
246 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
65 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
15 |
$795.48 |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
76 |
$502.36 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$256.18 |
| D0272 |
Bitewings - two radiographic images |
22 |
22 |
$243.98 |