| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
648 |
364 |
$50K |
| D1120 |
Prophylaxis - child |
1,154 |
1,080 |
$44K |
| D4342 |
|
257 |
147 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,311 |
1,174 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,133 |
1,061 |
$28K |
| D4341 |
|
167 |
62 |
$26K |
| D1110 |
Prophylaxis - adult |
469 |
458 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
878 |
809 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
285 |
184 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,168 |
1,092 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
219 |
184 |
$12K |
| D0330 |
Panoramic radiographic image |
521 |
503 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,650 |
1,479 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
431 |
409 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
108 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,465 |
1,313 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
182 |
155 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
40 |
31 |
$3K |
| D0272 |
Bitewings - two radiographic images |
201 |
185 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$764.55 |