| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
846 |
416 |
$67K |
| D1120 |
Prophylaxis - child |
1,513 |
1,357 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,474 |
1,340 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,274 |
1,138 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
425 |
345 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
807 |
778 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
983 |
916 |
$20K |
| D4341 |
|
116 |
72 |
$19K |
| D1110 |
Prophylaxis - adult |
440 |
429 |
$17K |
| D0274 |
Bitewings - four radiographic images |
956 |
838 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,606 |
1,449 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
244 |
202 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
341 |
331 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,329 |
1,182 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
54 |
$2K |
| D0272 |
Bitewings - two radiographic images |
239 |
222 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
27 |
$2K |