| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,630 |
554 |
$89K |
| D4341 |
|
539 |
264 |
$83K |
| D1120 |
Prophylaxis - child |
1,726 |
1,726 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,303 |
2,303 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,735 |
1,735 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,266 |
1,266 |
$24K |
| D1110 |
Prophylaxis - adult |
346 |
346 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
624 |
624 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
236 |
162 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
258 |
167 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,917 |
1,910 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,952 |
1,712 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
83 |
65 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
96 |
$5K |
| D4910 |
|
75 |
75 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
204 |
200 |
$4K |
| D0272 |
Bitewings - two radiographic images |
283 |
283 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
70 |
$932.02 |
| D0270 |
|
16 |
15 |
$89.60 |