| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,175 |
389 |
$59K |
| D1120 |
Prophylaxis - child |
1,081 |
1,080 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,210 |
1,210 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,045 |
1,044 |
$28K |
| D1110 |
Prophylaxis - adult |
526 |
526 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
922 |
920 |
$23K |
| D0274 |
Bitewings - four radiographic images |
950 |
949 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
197 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
231 |
112 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,532 |
1,517 |
$10K |
| D4341 |
|
78 |
30 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
306 |
305 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,516 |
1,306 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
277 |
274 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
82 |
$4K |
| D0272 |
Bitewings - two radiographic images |
223 |
223 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
27 |
$2K |