| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,829 |
649 |
$107K |
| D4341 |
|
665 |
260 |
$98K |
| D1120 |
Prophylaxis - child |
2,114 |
2,106 |
$89K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,199 |
703 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,436 |
2,429 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,057 |
2,049 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,075 |
2,068 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,091 |
1,087 |
$27K |
| D1110 |
Prophylaxis - adult |
522 |
521 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
3,260 |
3,234 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,650 |
2,640 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
911 |
902 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
55 |
$5K |
| D0272 |
Bitewings - two radiographic images |
338 |
336 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
26 |
$2K |
| D2331 |
|
14 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$728.00 |
| D1354 |
|
28 |
16 |
$553.00 |