| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,136 |
443 |
$74K |
| D1120 |
Prophylaxis - child |
1,360 |
1,358 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
687 |
435 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,422 |
1,420 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,350 |
1,348 |
$36K |
| D4341 |
|
211 |
110 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,176 |
1,171 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
831 |
829 |
$21K |
| D1110 |
Prophylaxis - adult |
418 |
416 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
285 |
167 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
109 |
90 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,650 |
1,636 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
236 |
186 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,572 |
1,441 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
166 |
164 |
$3K |
| D0272 |
Bitewings - two radiographic images |
183 |
183 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$301.33 |