| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,250 |
1,161 |
$167K |
| D1120 |
Prophylaxis - child |
4,015 |
3,601 |
$164K |
| D1206 |
Topical application of fluoride varnish |
3,131 |
2,752 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,267 |
1,994 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
625 |
526 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,500 |
1,348 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,057 |
943 |
$18K |
| D0330 |
Panoramic radiographic image |
609 |
535 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
369 |
366 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
183 |
156 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
67 |
55 |
$4K |
| D1110 |
Prophylaxis - adult |
62 |
60 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
325 |
280 |
$2K |
| D0272 |
Bitewings - two radiographic images |
161 |
141 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
54 |
$874.80 |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$541.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$91.20 |