| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,140 |
765 |
$116K |
| D1120 |
Prophylaxis - child |
2,098 |
2,096 |
$89K |
| D4341 |
|
505 |
239 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,718 |
2,709 |
$76K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
585 |
394 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
795 |
519 |
$51K |
| D1110 |
Prophylaxis - adult |
875 |
869 |
$41K |
| D0274 |
Bitewings - four radiographic images |
2,145 |
2,134 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,467 |
1,466 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
806 |
493 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,041 |
1,037 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
3,028 |
2,996 |
$20K |
| D2332 |
|
174 |
64 |
$19K |
| D1206 |
Topical application of fluoride varnish |
552 |
552 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,701 |
2,645 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
513 |
504 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
89 |
55 |
$8K |
| D0272 |
Bitewings - two radiographic images |
362 |
361 |
$4K |
| D9110 |
|
19 |
18 |
$825.00 |