| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
662 |
319 |
$48K |
| D1120 |
Prophylaxis - child |
844 |
844 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,030 |
1,029 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
833 |
833 |
$23K |
| D4341 |
|
104 |
47 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
272 |
184 |
$18K |
| D0274 |
Bitewings - four radiographic images |
770 |
769 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
379 |
379 |
$10K |
| D1110 |
Prophylaxis - adult |
200 |
200 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,230 |
1,220 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
988 |
987 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
285 |
283 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
34 |
26 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
129 |
129 |
$1K |