| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,391 |
412 |
$79K |
| D1120 |
Prophylaxis - child |
1,528 |
1,511 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
2,009 |
1,987 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,268 |
2,241 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
395 |
207 |
$47K |
| D1110 |
Prophylaxis - adult |
775 |
762 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
555 |
539 |
$23K |
| D0274 |
Bitewings - four radiographic images |
794 |
776 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
67 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
209 |
$10K |
| D0330 |
Panoramic radiographic image |
173 |
169 |
$7K |
| D1330 |
|
1,156 |
1,140 |
$7K |
| D0272 |
Bitewings - two radiographic images |
364 |
359 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
613 |
573 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
31 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
354 |
340 |
$2K |
| D7111 |
|
24 |
13 |
$648.00 |