| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,784 |
1,427 |
$228K |
| D1120 |
Prophylaxis - child |
4,782 |
4,583 |
$196K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,697 |
1,808 |
$188K |
| D0120 |
Periodic oral evaluation - established patient |
5,380 |
5,230 |
$147K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,531 |
1,027 |
$96K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,566 |
3,537 |
$95K |
| D1110 |
Prophylaxis - adult |
2,033 |
1,986 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,394 |
3,283 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,679 |
1,205 |
$74K |
| D4341 |
|
505 |
282 |
$73K |
| D0210 |
Intraoral - complete series of radiographic images |
2,299 |
2,274 |
$73K |
| D0274 |
Bitewings - four radiographic images |
3,209 |
3,109 |
$58K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
593 |
478 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
5,782 |
5,532 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,149 |
954 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,952 |
4,619 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
1,051 |
1,009 |
$21K |
| D0272 |
Bitewings - two radiographic images |
970 |
869 |
$9K |
| D2331 |
|
51 |
40 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
36 |
30 |
$2K |
| D0330 |
Panoramic radiographic image |
63 |
63 |
$1K |
| D2950 |
|
17 |
13 |
$1K |
| D2330 |
|
15 |
12 |
$865.00 |
| D0601 |
|
15 |
12 |
$0.00 |