| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
9,958 |
1,082 |
$225K |
| D0330 |
Panoramic radiographic image |
2,679 |
2,222 |
$109K |
| D1120 |
Prophylaxis - child |
4,495 |
3,617 |
$95K |
| D0140 |
Limited oral evaluation - problem focused |
2,821 |
2,258 |
$83K |
| D0274 |
Bitewings - four radiographic images |
3,875 |
3,134 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,147 |
1,576 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,280 |
1,993 |
$48K |
| D1206 |
Topical application of fluoride varnish |
2,072 |
1,820 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
502 |
241 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,412 |
1,796 |
$26K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
346 |
127 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
225 |
117 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,202 |
944 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
51 |
$6K |
| D1999 |
|
5,109 |
4,023 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
414 |
342 |
$4K |
| D0272 |
Bitewings - two radiographic images |
153 |
114 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
25 |
$734.00 |
| D1330 |
|
5,370 |
4,277 |
$0.00 |