| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
14,019 |
2,087 |
$462K |
| D0120 |
Periodic oral evaluation - established patient |
14,588 |
14,384 |
$432K |
| D1110 |
Prophylaxis - adult |
6,801 |
6,713 |
$411K |
| D1120 |
Prophylaxis - child |
9,219 |
9,085 |
$400K |
| D1206 |
Topical application of fluoride varnish |
13,539 |
13,341 |
$336K |
| D0274 |
Bitewings - four radiographic images |
8,348 |
8,230 |
$188K |
| D0330 |
Panoramic radiographic image |
3,489 |
3,441 |
$150K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,152 |
738 |
$136K |
| D0272 |
Bitewings - two radiographic images |
5,564 |
5,485 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,472 |
1,454 |
$79K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,612 |
2,585 |
$60K |
| D1330 |
|
8,666 |
8,546 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
562 |
379 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
162 |
122 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,625 |
1,563 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
340 |
338 |
$15K |
| D9944 |
|
47 |
47 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
38 |
$6K |
| D3120 |
|
166 |
126 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
45 |
$409.20 |