| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,795 |
1,408 |
$128K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,688 |
1,667 |
$64K |
| D1120 |
Prophylaxis - child |
2,963 |
2,928 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,439 |
2,412 |
$58K |
| D0330 |
Panoramic radiographic image |
1,444 |
1,437 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,964 |
3,921 |
$43K |
| D1110 |
Prophylaxis - adult |
989 |
981 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
223 |
220 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
39 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$1K |
| D2940 |
|
20 |
14 |
$700.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$117.00 |