| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,617 |
1,261 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
4,605 |
4,605 |
$95K |
| D1110 |
Prophylaxis - adult |
2,264 |
2,264 |
$93K |
| D0274 |
Bitewings - four radiographic images |
4,237 |
4,237 |
$87K |
| D1354 |
|
5,534 |
961 |
$83K |
| D1120 |
Prophylaxis - child |
2,682 |
2,682 |
$82K |
| D1206 |
Topical application of fluoride varnish |
3,294 |
3,294 |
$72K |
| D0220 |
Intraoral - periapical first radiographic image |
4,922 |
4,905 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,781 |
4,775 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
801 |
625 |
$41K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
300 |
278 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,643 |
1,643 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
387 |
387 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
350 |
349 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
65 |
52 |
$2K |
| D2394 |
|
15 |
13 |
$1K |