| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
406 |
186 |
$25K |
| D1120 |
Prophylaxis - child |
503 |
501 |
$20K |
| D4341 |
|
128 |
82 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
719 |
715 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
500 |
498 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
191 |
153 |
$12K |
| D0274 |
Bitewings - four radiographic images |
417 |
413 |
$8K |
| D1110 |
Prophylaxis - adult |
142 |
140 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
236 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
96 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
656 |
647 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
56 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
643 |
558 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
32 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
116 |
114 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
103 |
$2K |
| D0272 |
Bitewings - two radiographic images |
117 |
117 |
$1K |
| D0270 |
|
14 |
14 |
$78.40 |
| D1999 |
|
395 |
373 |
$0.00 |