| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,299 |
480 |
$86K |
| D0330 |
Panoramic radiographic image |
1,291 |
1,149 |
$59K |
| D1120 |
Prophylaxis - child |
2,359 |
2,093 |
$58K |
| D0140 |
Limited oral evaluation - problem focused |
1,674 |
1,331 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
3,841 |
3,004 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,421 |
2,154 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,104 |
2,312 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,125 |
1,893 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
708 |
630 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,156 |
1,043 |
$27K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
19 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$994.92 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$853.90 |