| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,858 |
358 |
$44K |
| D1110 |
Prophylaxis - adult |
945 |
941 |
$32K |
| D0274 |
Bitewings - four radiographic images |
917 |
913 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,169 |
1,166 |
$23K |
| D1120 |
Prophylaxis - child |
558 |
556 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
252 |
116 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
104 |
$10K |
| D1206 |
Topical application of fluoride varnish |
542 |
541 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
483 |
480 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,160 |
1,152 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,147 |
959 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
117 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
232 |
230 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
30 |
$3K |
| D0272 |
Bitewings - two radiographic images |
65 |
65 |
$1K |
| D2330 |
|
20 |
12 |
$899.42 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$269.70 |