| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,065 |
576 |
$102K |
| D1110 |
Prophylaxis - adult |
1,408 |
1,345 |
$65K |
| D1120 |
Prophylaxis - child |
1,401 |
1,376 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,857 |
1,808 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,749 |
1,723 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
733 |
696 |
$31K |
| D0274 |
Bitewings - four radiographic images |
663 |
624 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
135 |
63 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
332 |
321 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
949 |
902 |
$7K |
| D0272 |
Bitewings - two radiographic images |
390 |
384 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
38 |
$5K |
| D0330 |
Panoramic radiographic image |
136 |
134 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
26 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
206 |
202 |
$1K |