| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,187 |
912 |
$147K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,720 |
728 |
$139K |
| D4341 |
|
775 |
323 |
$125K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
847 |
581 |
$86K |
| D1120 |
Prophylaxis - child |
1,987 |
1,987 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,519 |
2,519 |
$72K |
| D4342 |
|
694 |
352 |
$71K |
| D1110 |
Prophylaxis - adult |
1,452 |
1,452 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
673 |
484 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,811 |
1,808 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
432 |
326 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,646 |
1,646 |
$45K |
| D0330 |
Panoramic radiographic image |
1,604 |
1,602 |
$38K |
| D5110 |
|
68 |
68 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
917 |
916 |
$27K |
| D0274 |
Bitewings - four radiographic images |
989 |
988 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,925 |
2,919 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,765 |
2,763 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
318 |
318 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
166 |
135 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
366 |
361 |
$7K |
| D5120 |
|
14 |
14 |
$6K |
| D2332 |
|
41 |
29 |
$4K |
| D0272 |
Bitewings - two radiographic images |
335 |
334 |
$4K |
| D2335 |
|
13 |
12 |
$2K |
| D2331 |
|
18 |
12 |
$1K |