| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,773 |
557 |
$87K |
| D1120 |
Prophylaxis - child |
1,859 |
1,853 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,395 |
2,375 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
807 |
526 |
$52K |
| D7140 |
Extraction, erupted tooth or exposed root |
729 |
343 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,804 |
1,798 |
$47K |
| D4341 |
|
358 |
170 |
$46K |
| D1110 |
Prophylaxis - adult |
665 |
657 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,046 |
1,043 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
814 |
806 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,224 |
1,217 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
196 |
145 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
676 |
665 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
2,076 |
2,037 |
$12K |
| D0330 |
Panoramic radiographic image |
360 |
354 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,708 |
1,570 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
78 |
$4K |
| D0272 |
Bitewings - two radiographic images |
68 |
68 |
$669.73 |