| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,293 |
283 |
$32K |
| D1120 |
Prophylaxis - child |
411 |
407 |
$12K |
| D1206 |
Topical application of fluoride varnish |
520 |
513 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
58 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
280 |
279 |
$6K |
| D0272 |
Bitewings - two radiographic images |
327 |
324 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
63 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
197 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
25 |
$3K |
| D1110 |
Prophylaxis - adult |
60 |
60 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
246 |
208 |
$2K |
| D0274 |
Bitewings - four radiographic images |
68 |
68 |
$2K |
| D1354 |
|
242 |
89 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
216 |
211 |
$2K |