| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,153 |
1,211 |
$174K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,745 |
790 |
$148K |
| D1110 |
Prophylaxis - adult |
3,732 |
3,480 |
$137K |
| D1120 |
Prophylaxis - child |
3,188 |
2,951 |
$120K |
| D0120 |
Periodic oral evaluation - established patient |
4,354 |
3,866 |
$113K |
| D0330 |
Panoramic radiographic image |
3,953 |
3,684 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,726 |
3,487 |
$74K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,113 |
504 |
$74K |
| D1206 |
Topical application of fluoride varnish |
3,063 |
2,841 |
$71K |
| D5110 |
|
149 |
138 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
5,871 |
5,412 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
460 |
346 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,681 |
1,555 |
$27K |
| D5120 |
|
62 |
54 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
2,484 |
2,321 |
$20K |
| D2332 |
|
207 |
119 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
238 |
164 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,244 |
3,671 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,401 |
1,304 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
198 |
169 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
671 |
637 |
$10K |
| D4342 |
|
39 |
13 |
$3K |
| D4341 |
|
19 |
12 |
$3K |
| D2331 |
|
25 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
39 |
$986.25 |
| D1999 |
|
714 |
577 |
$0.00 |