| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,151 |
447 |
$74K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
677 |
411 |
$60K |
| D4341 |
|
368 |
153 |
$56K |
| D1120 |
Prophylaxis - child |
1,149 |
1,147 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,370 |
1,366 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
533 |
340 |
$36K |
| D7140 |
Extraction, erupted tooth or exposed root |
464 |
291 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,121 |
1,119 |
$29K |
| D1110 |
Prophylaxis - adult |
609 |
608 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,195 |
1,188 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
886 |
879 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
259 |
210 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
991 |
963 |
$18K |
| D2332 |
|
178 |
116 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,501 |
2,463 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
334 |
213 |
$14K |
| D4342 |
|
84 |
57 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,970 |
1,856 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
320 |
318 |
$8K |
| D2335 |
|
74 |
59 |
$6K |
| D0272 |
Bitewings - two radiographic images |
247 |
247 |
$3K |
| D2331 |
|
16 |
12 |
$1K |
| D0270 |
|
208 |
207 |
$1K |
| D9110 |
|
28 |
28 |
$1K |
| D2330 |
|
16 |
12 |
$1K |