| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,356 |
5,270 |
$149K |
| D4342 |
|
874 |
581 |
$133K |
| D1351 |
Sealant - per tooth |
1,591 |
763 |
$126K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,246 |
836 |
$121K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,464 |
745 |
$104K |
| D1120 |
Prophylaxis - child |
2,298 |
2,269 |
$95K |
| D4341 |
|
551 |
222 |
$83K |
| D1110 |
Prophylaxis - adult |
1,639 |
1,636 |
$77K |
| D0210 |
Intraoral - complete series of radiographic images |
2,015 |
1,976 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,216 |
2,193 |
$58K |
| D0330 |
Panoramic radiographic image |
1,412 |
1,390 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
3,116 |
3,030 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
310 |
281 |
$20K |
| D0274 |
Bitewings - four radiographic images |
919 |
908 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,921 |
2,839 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
242 |
219 |
$11K |
| D5120 |
|
12 |
12 |
$5K |
| D5110 |
|
12 |
12 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
149 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
153 |
153 |
$3K |
| D0272 |
Bitewings - two radiographic images |
190 |
189 |
$2K |
| D2335 |
|
13 |
13 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
24 |
$650.00 |