| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,706 |
873 |
$137K |
| D4341 |
|
722 |
403 |
$121K |
| D1120 |
Prophylaxis - child |
2,776 |
2,761 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
3,273 |
3,256 |
$94K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,088 |
763 |
$90K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,726 |
2,709 |
$73K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
800 |
586 |
$42K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
358 |
288 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,511 |
1,503 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
261 |
204 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,079 |
1,043 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
3,754 |
3,720 |
$24K |
| D1110 |
Prophylaxis - adult |
406 |
405 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,368 |
3,354 |
$15K |
| D2332 |
|
111 |
65 |
$15K |
| D0272 |
Bitewings - two radiographic images |
774 |
757 |
$8K |
| D0330 |
Panoramic radiographic image |
345 |
326 |
$7K |
| D0270 |
|
1,173 |
1,171 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
331 |
325 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
69 |
$6K |
| D9110 |
|
99 |
99 |
$5K |
| D2330 |
|
44 |
36 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
123 |
113 |
$3K |
| D4342 |
|
26 |
13 |
$3K |
| D4910 |
|
13 |
13 |
$804.00 |