| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,504 |
665 |
$115K |
| D1110 |
Prophylaxis - adult |
1,868 |
1,492 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,041 |
400 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
3,381 |
2,548 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,750 |
2,859 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,565 |
1,674 |
$45K |
| D1120 |
Prophylaxis - child |
2,136 |
1,536 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,301 |
1,012 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,505 |
1,884 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
300 |
142 |
$15K |
| D0272 |
Bitewings - two radiographic images |
557 |
392 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
74 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
105 |
77 |
$2K |
| D0330 |
Panoramic radiographic image |
48 |
42 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
13 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$2K |