| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,914 |
721 |
$86K |
| D1110 |
Prophylaxis - adult |
781 |
711 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,373 |
1,252 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,571 |
1,416 |
$25K |
| D0274 |
Bitewings - four radiographic images |
857 |
757 |
$23K |
| D1120 |
Prophylaxis - child |
726 |
638 |
$20K |
| D0330 |
Panoramic radiographic image |
280 |
248 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
992 |
882 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
843 |
741 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
27 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
85 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
66 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$1K |