| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
2,602 |
1,177 |
$197K |
| D4341 |
|
932 |
351 |
$160K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,167 |
1,175 |
$143K |
| D1120 |
Prophylaxis - child |
2,756 |
2,556 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
3,199 |
2,907 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,024 |
729 |
$75K |
| D1110 |
Prophylaxis - adult |
1,207 |
1,173 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,322 |
2,164 |
$51K |
| D0274 |
Bitewings - four radiographic images |
3,024 |
2,790 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,746 |
1,619 |
$44K |
| D4342 |
|
243 |
141 |
$38K |
| D5110 |
|
81 |
81 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
662 |
491 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
5,138 |
4,624 |
$30K |
| D1206 |
Topical application of fluoride varnish |
951 |
900 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
257 |
219 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,819 |
4,347 |
$19K |
| D5120 |
|
37 |
37 |
$16K |
| D0330 |
Panoramic radiographic image |
599 |
569 |
$12K |
| D0272 |
Bitewings - two radiographic images |
997 |
893 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
435 |
409 |
$7K |
| D2335 |
|
15 |
12 |
$988.80 |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
25 |
$702.20 |
| D0270 |
|
124 |
119 |
$694.40 |
| D1999 |
|
100 |
89 |
$0.00 |