| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,171 |
370 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
280 |
207 |
$47K |
| D1120 |
Prophylaxis - child |
823 |
809 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,193 |
1,180 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
879 |
855 |
$33K |
| D1110 |
Prophylaxis - adult |
503 |
503 |
$32K |
| D0330 |
Panoramic radiographic image |
376 |
376 |
$31K |
| D0274 |
Bitewings - four radiographic images |
581 |
578 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
370 |
367 |
$24K |
| D0272 |
Bitewings - two radiographic images |
503 |
497 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
66 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
65 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
328 |
320 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
96 |
$5K |