| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,196 |
643 |
$110K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,019 |
617 |
$107K |
| D1120 |
Prophylaxis - child |
1,864 |
1,755 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,412 |
2,167 |
$66K |
| D1110 |
Prophylaxis - adult |
1,216 |
1,181 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,563 |
1,463 |
$40K |
| D0274 |
Bitewings - four radiographic images |
2,003 |
1,860 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,464 |
1,377 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
409 |
355 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,447 |
3,038 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
346 |
304 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
4,098 |
3,708 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
217 |
187 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
560 |
533 |
$9K |
| D5120 |
|
14 |
14 |
$5K |
| D5110 |
|
14 |
14 |
$5K |
| D0270 |
|
427 |
399 |
$2K |
| D2335 |
|
21 |
14 |
$2K |
| D2394 |
|
27 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
106 |
99 |
$977.60 |