| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,477 |
500 |
$86K |
| D7140 |
Extraction, erupted tooth or exposed root |
819 |
398 |
$56K |
| D1120 |
Prophylaxis - child |
1,284 |
1,284 |
$54K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
520 |
307 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,594 |
1,593 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
538 |
361 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,273 |
1,272 |
$34K |
| D1110 |
Prophylaxis - adult |
684 |
684 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,079 |
1,078 |
$30K |
| D4341 |
|
209 |
73 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,177 |
1,176 |
$22K |
| D0330 |
Panoramic radiographic image |
816 |
813 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,289 |
2,281 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
315 |
248 |
$13K |
| D5120 |
|
29 |
29 |
$12K |
| D5110 |
|
28 |
28 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,101 |
2,096 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
371 |
365 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
45 |
$6K |
| D2332 |
|
54 |
41 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
239 |
239 |
$5K |
| D0272 |
Bitewings - two radiographic images |
360 |
359 |
$4K |
| D2335 |
|
30 |
26 |
$3K |
| D4342 |
|
34 |
12 |
$3K |
| D2330 |
|
43 |
27 |
$2K |