| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,650 |
1,032 |
$154K |
| D1120 |
Prophylaxis - child |
2,259 |
2,258 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
2,443 |
2,442 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,241 |
2,240 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
524 |
439 |
$39K |
| D4341 |
|
179 |
106 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,290 |
1,290 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
360 |
305 |
$18K |
| D1110 |
Prophylaxis - adult |
364 |
364 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
632 |
632 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,752 |
1,736 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
108 |
93 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,421 |
1,412 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
261 |
256 |
$5K |
| D0272 |
Bitewings - two radiographic images |
400 |
399 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
39 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$496.84 |