| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,441 |
556 |
$94K |
| D1120 |
Prophylaxis - child |
1,864 |
1,822 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,749 |
1,685 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,824 |
1,785 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,653 |
1,621 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,836 |
1,784 |
$30K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
305 |
254 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,338 |
3,077 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
361 |
311 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
3,508 |
3,368 |
$22K |
| D1110 |
Prophylaxis - adult |
463 |
461 |
$21K |
| D4341 |
|
103 |
58 |
$14K |
| D5110 |
|
26 |
26 |
$12K |
| D0330 |
Panoramic radiographic image |
381 |
376 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
178 |
158 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
65 |
$6K |
| D5120 |
|
13 |
13 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
116 |
116 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
16 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
28 |
$754.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$301.08 |