| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
8,022 |
839 |
$165K |
| D1120 |
Prophylaxis - child |
6,755 |
5,247 |
$137K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,317 |
666 |
$109K |
| D0210 |
Intraoral - complete series of radiographic images |
2,330 |
1,750 |
$102K |
| D1206 |
Topical application of fluoride varnish |
6,105 |
4,628 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,199 |
2,968 |
$89K |
| D0140 |
Limited oral evaluation - problem focused |
2,741 |
2,097 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,771 |
2,439 |
$58K |
| D0330 |
Panoramic radiographic image |
2,208 |
1,675 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
619 |
214 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
526 |
223 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,883 |
1,193 |
$16K |
| D0274 |
Bitewings - four radiographic images |
968 |
792 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,508 |
1,167 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
26 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
101 |
90 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$752.40 |
| D1110 |
Prophylaxis - adult |
43 |
26 |
$537.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
28 |
$103.68 |