| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
5,530 |
1,139 |
$144K |
| D1110 |
Prophylaxis - adult |
4,076 |
3,824 |
$137K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,692 |
995 |
$101K |
| D0274 |
Bitewings - four radiographic images |
4,083 |
3,807 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
4,721 |
4,434 |
$90K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,312 |
783 |
$64K |
| D1120 |
Prophylaxis - child |
1,972 |
1,878 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,370 |
4,169 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
5,267 |
4,928 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,209 |
2,089 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
787 |
727 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,588 |
1,443 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,329 |
1,305 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
354 |
270 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
368 |
196 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
366 |
351 |
$14K |
| D0272 |
Bitewings - two radiographic images |
526 |
494 |
$7K |
| D0270 |
|
254 |
245 |
$2K |
| D2331 |
|
16 |
14 |
$903.86 |
| D2335 |
|
12 |
12 |
$811.80 |