| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,409 |
511 |
$92K |
| D1120 |
Prophylaxis - child |
1,724 |
1,724 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,086 |
2,085 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
817 |
572 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,656 |
1,656 |
$44K |
| D1110 |
Prophylaxis - adult |
862 |
860 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
552 |
399 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,676 |
1,674 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,078 |
1,076 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
442 |
359 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
116 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,898 |
1,889 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,704 |
1,286 |
$10K |
| D4341 |
|
69 |
36 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
432 |
429 |
$8K |
| D0272 |
Bitewings - two radiographic images |
359 |
359 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
165 |
164 |
$3K |