| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,490 |
1,857 |
$306K |
| D4341 |
|
1,379 |
564 |
$244K |
| D4342 |
|
1,015 |
743 |
$197K |
| D0120 |
Periodic oral evaluation - established patient |
6,712 |
6,622 |
$184K |
| D1120 |
Prophylaxis - child |
4,578 |
4,543 |
$184K |
| D1206 |
Topical application of fluoride varnish |
4,531 |
4,496 |
$116K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,100 |
813 |
$95K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,035 |
668 |
$79K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
676 |
533 |
$62K |
| D0274 |
Bitewings - four radiographic images |
3,554 |
3,498 |
$57K |
| D1110 |
Prophylaxis - adult |
1,365 |
1,360 |
$56K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
419 |
347 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,662 |
1,621 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
1,295 |
1,241 |
$33K |
| D0330 |
Panoramic radiographic image |
1,560 |
1,533 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
4,386 |
4,294 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
1,178 |
1,148 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,349 |
4,264 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
105 |
$8K |
| D0272 |
Bitewings - two radiographic images |
610 |
603 |
$6K |
| D2950 |
|
63 |
54 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
36 |
35 |
$900.40 |