| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,535 |
952 |
$143K |
| D1110 |
Prophylaxis - adult |
3,237 |
2,979 |
$116K |
| D1120 |
Prophylaxis - child |
2,688 |
2,499 |
$101K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,460 |
909 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
3,799 |
3,441 |
$94K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,478 |
531 |
$80K |
| D0330 |
Panoramic radiographic image |
3,150 |
2,939 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,655 |
2,470 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,872 |
2,683 |
$57K |
| D5110 |
|
120 |
119 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
5,360 |
4,948 |
$28K |
| D5120 |
|
67 |
67 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,376 |
1,249 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
347 |
216 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
1,989 |
1,853 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,662 |
3,250 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
175 |
97 |
$9K |
| D2332 |
|
91 |
57 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
282 |
264 |
$4K |
| D4341 |
|
21 |
12 |
$4K |
| D0272 |
Bitewings - two radiographic images |
101 |
96 |
$891.10 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$771.25 |
| D1999 |
|
565 |
451 |
$0.00 |