| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,279 |
338 |
$47K |
| D1120 |
Prophylaxis - child |
907 |
880 |
$35K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
458 |
183 |
$26K |
| D5110 |
|
66 |
66 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
831 |
809 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
744 |
715 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
460 |
166 |
$19K |
| D5120 |
|
41 |
41 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
611 |
597 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
223 |
129 |
$10K |
| D0274 |
Bitewings - four radiographic images |
624 |
607 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,101 |
1,064 |
$6K |
| D2332 |
|
89 |
51 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
168 |
99 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,021 |
956 |
$5K |
| D0330 |
Panoramic radiographic image |
197 |
191 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
202 |
195 |
$3K |
| D0272 |
Bitewings - two radiographic images |
227 |
221 |
$2K |
| D1110 |
Prophylaxis - adult |
77 |
71 |
$2K |
| D1206 |
Topical application of fluoride varnish |
69 |
64 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
122 |
118 |
$537.00 |
| D0601 |
|
48 |
44 |
$0.00 |