| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,570 |
425 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
715 |
291 |
$34K |
| D1110 |
Prophylaxis - adult |
1,104 |
993 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,308 |
1,161 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
316 |
214 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
965 |
846 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,533 |
1,367 |
$18K |
| D2335 |
|
334 |
133 |
$18K |
| D1120 |
Prophylaxis - child |
1,037 |
902 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,394 |
2,089 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,738 |
1,972 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,232 |
1,085 |
$12K |
| D0272 |
Bitewings - two radiographic images |
766 |
667 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
119 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
265 |
119 |
$7K |
| D2330 |
|
155 |
76 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
214 |
190 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
15 |
$1K |
| D2331 |
|
56 |
35 |
$987.71 |
| D1206 |
Topical application of fluoride varnish |
30 |
27 |
$623.00 |
| D2332 |
|
30 |
15 |
$223.16 |
| D9920 |
|
21 |
18 |
$0.00 |