| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
7,492 |
3,423 |
$460K |
| D7140 |
Extraction, erupted tooth or exposed root |
5,997 |
2,784 |
$373K |
| D1120 |
Prophylaxis - child |
8,892 |
8,503 |
$360K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
3,205 |
1,865 |
$248K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
9,544 |
9,071 |
$212K |
| D0120 |
Periodic oral evaluation - established patient |
6,487 |
6,057 |
$178K |
| D1206 |
Topical application of fluoride varnish |
5,331 |
5,020 |
$134K |
| D0274 |
Bitewings - four radiographic images |
6,580 |
6,235 |
$111K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,409 |
11,856 |
$107K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,288 |
1,001 |
$83K |
| D0220 |
Intraoral - periapical first radiographic image |
13,979 |
12,979 |
$81K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,647 |
2,629 |
$70K |
| D1110 |
Prophylaxis - adult |
1,618 |
1,539 |
$67K |
| D0330 |
Panoramic radiographic image |
2,162 |
2,083 |
$47K |
| D0140 |
Limited oral evaluation - problem focused |
2,564 |
2,450 |
$42K |
| D5110 |
|
97 |
97 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
750 |
576 |
$32K |
| D5120 |
|
48 |
48 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,654 |
1,563 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
198 |
172 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
754 |
705 |
$10K |
| D4341 |
|
19 |
13 |
$4K |
| D7240 |
Removal of impacted tooth - completely bony |
28 |
25 |
$3K |
| D2332 |
|
31 |
25 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
49 |
42 |
$1K |
| D2330 |
|
14 |
13 |
$772.80 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
13 |
12 |
$625.95 |
| D0270 |
|
13 |
13 |
$72.80 |