| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,115 |
999 |
$151K |
| D1120 |
Prophylaxis - child |
3,478 |
3,195 |
$141K |
| D4341 |
|
651 |
391 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
3,777 |
3,472 |
$104K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,393 |
3,130 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
868 |
625 |
$65K |
| D7140 |
Extraction, erupted tooth or exposed root |
704 |
414 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,934 |
1,823 |
$42K |
| D1110 |
Prophylaxis - adult |
808 |
778 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
1,171 |
1,131 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,956 |
1,769 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
3,409 |
3,031 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
837 |
782 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,701 |
2,365 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
205 |
$10K |
| D0272 |
Bitewings - two radiographic images |
425 |
369 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
32 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$784.00 |