| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
231 |
165 |
$25K |
| D4341 |
|
96 |
57 |
$17K |
| D1120 |
Prophylaxis - child |
385 |
368 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
420 |
381 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
380 |
362 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
373 |
339 |
$8K |
| D0274 |
Bitewings - four radiographic images |
481 |
445 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
81 |
$6K |
| D1110 |
Prophylaxis - adult |
138 |
134 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
808 |
741 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
754 |
684 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
75 |
59 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
49 |
38 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
109 |
$2K |
| D2140 |
|
46 |
37 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
31 |
$1K |
| D0272 |
Bitewings - two radiographic images |
107 |
104 |
$968.40 |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
27 |
$770.10 |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$644.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$584.51 |
| D0270 |
|
84 |
80 |
$470.40 |