| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,638 |
437 |
$80K |
| D1110 |
Prophylaxis - adult |
1,801 |
1,801 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
2,342 |
2,339 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
588 |
291 |
$44K |
| D0330 |
Panoramic radiographic image |
996 |
996 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,254 |
1,254 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,345 |
1,344 |
$25K |
| D1120 |
Prophylaxis - child |
645 |
644 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
495 |
488 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
235 |
190 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
235 |
168 |
$12K |
| D1330 |
|
1,451 |
1,450 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,287 |
1,280 |
$10K |
| D1310 |
|
1,172 |
1,171 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
384 |
384 |
$8K |
| D0272 |
Bitewings - two radiographic images |
347 |
346 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
743 |
741 |
$6K |
| D0602 |
|
71 |
71 |
$680.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
36 |
36 |
$655.01 |