| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,531 |
564 |
$96K |
| D4341 |
|
471 |
250 |
$73K |
| D1120 |
Prophylaxis - child |
1,563 |
1,561 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,737 |
1,732 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,441 |
1,439 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,414 |
1,406 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,003 |
999 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
362 |
282 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
325 |
238 |
$22K |
| D1110 |
Prophylaxis - adult |
455 |
452 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
172 |
130 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,101 |
2,075 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,983 |
1,764 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
119 |
106 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
157 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
344 |
341 |
$6K |
| D4342 |
|
23 |
13 |
$3K |
| D0272 |
Bitewings - two radiographic images |
158 |
158 |
$2K |
| D4910 |
|
14 |
14 |
$871.00 |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$306.30 |