| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,776 |
873 |
$135K |
| D0274 |
Bitewings - four radiographic images |
4,977 |
4,911 |
$124K |
| D1110 |
Prophylaxis - adult |
3,759 |
3,712 |
$121K |
| D0120 |
Periodic oral evaluation - established patient |
4,615 |
4,556 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,684 |
2,641 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,431 |
3,206 |
$48K |
| D1120 |
Prophylaxis - child |
1,590 |
1,577 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
695 |
429 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,337 |
2,309 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
4,292 |
4,196 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
232 |
145 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
195 |
89 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
186 |
186 |
$8K |
| D0272 |
Bitewings - two radiographic images |
442 |
437 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
180 |
179 |
$7K |
| D5110 |
|
17 |
17 |
$6K |
| D5120 |
|
13 |
13 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
37 |
$3K |
| D1206 |
Topical application of fluoride varnish |
66 |
66 |
$1K |
| D1999 |
|
87 |
86 |
$28.00 |