| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,920 |
186 |
$28K |
| D1120 |
Prophylaxis - child |
781 |
458 |
$19K |
| D0274 |
Bitewings - four radiographic images |
1,157 |
730 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
577 |
378 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
300 |
70 |
$10K |
| D2140 |
|
427 |
84 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,245 |
725 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
469 |
269 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,310 |
825 |
$8K |
| D0350 |
|
584 |
419 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
358 |
81 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
134 |
40 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
735 |
456 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
415 |
242 |
$3K |
| D1206 |
Topical application of fluoride varnish |
124 |
76 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
72 |
60 |
$2K |
| D4355 |
|
152 |
50 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
14 |
$536.12 |
| D0272 |
Bitewings - two radiographic images |
21 |
12 |
$216.00 |