| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,765 |
925 |
$114K |
| D1110 |
Prophylaxis - adult |
2,365 |
2,358 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
3,072 |
3,062 |
$59K |
| D0274 |
Bitewings - four radiographic images |
1,902 |
1,894 |
$50K |
| D1120 |
Prophylaxis - child |
1,425 |
1,421 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,864 |
1,862 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
633 |
339 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
414 |
254 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,073 |
1,069 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,562 |
2,536 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,329 |
2,117 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
393 |
391 |
$16K |
| D0272 |
Bitewings - two radiographic images |
698 |
695 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
137 |
92 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
185 |
182 |
$3K |
| D2330 |
|
74 |
37 |
$3K |
| D1206 |
Topical application of fluoride varnish |
114 |
113 |
$2K |