| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,528 |
677 |
$83K |
| D1110 |
Prophylaxis - adult |
1,707 |
1,607 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,585 |
2,454 |
$56K |
| D1120 |
Prophylaxis - child |
1,659 |
1,579 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
566 |
314 |
$41K |
| D0272 |
Bitewings - two radiographic images |
914 |
864 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
628 |
585 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
215 |
206 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
182 |
106 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
86 |
$9K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$906.30 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
25 |
$329.76 |