| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,454 |
1,082 |
$155K |
| D1120 |
Prophylaxis - child |
3,142 |
3,131 |
$131K |
| D0120 |
Periodic oral evaluation - established patient |
3,623 |
3,604 |
$103K |
| D4341 |
|
591 |
196 |
$86K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,117 |
3,105 |
$82K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
656 |
347 |
$59K |
| D0274 |
Bitewings - four radiographic images |
3,031 |
3,010 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
702 |
410 |
$41K |
| D2332 |
|
332 |
151 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,198 |
1,189 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
4,380 |
4,334 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,942 |
4,083 |
$25K |
| D1110 |
Prophylaxis - adult |
506 |
500 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
293 |
202 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
217 |
131 |
$12K |
| D4910 |
|
123 |
122 |
$8K |
| D4342 |
|
61 |
26 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
365 |
354 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
71 |
$4K |
| D0330 |
Panoramic radiographic image |
247 |
244 |
$4K |
| D0272 |
Bitewings - two radiographic images |
330 |
329 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
127 |
126 |
$716.03 |
| D9110 |
|
12 |
12 |
$660.00 |
| D0270 |
|
53 |
49 |
$292.11 |