| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
2,376 |
2,242 |
$108K |
| D1351 |
Sealant - per tooth |
3,667 |
382 |
$73K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
759 |
317 |
$71K |
| D1110 |
Prophylaxis - adult |
1,617 |
1,516 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,050 |
1,930 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
771 |
396 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
2,638 |
2,406 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
854 |
800 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
232 |
145 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
350 |
178 |
$15K |
| D2394 |
|
151 |
107 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
740 |
691 |
$12K |
| D1120 |
Prophylaxis - child |
383 |
359 |
$10K |
| D1206 |
Topical application of fluoride varnish |
707 |
639 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
435 |
399 |
$7K |
| D2335 |
|
90 |
47 |
$6K |
| D0274 |
Bitewings - four radiographic images |
304 |
287 |
$6K |
| D2332 |
|
67 |
24 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
536 |
444 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
73 |
39 |
$3K |
| D2940 |
|
108 |
60 |
$3K |
| D2331 |
|
23 |
12 |
$1K |
| D7311 |
|
24 |
15 |
$624.30 |
| D9110 |
|
20 |
19 |
$450.98 |
| D9910 |
|
24 |
21 |
$281.39 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$246.95 |