| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
273 |
121 |
$44K |
| D1351 |
Sealant - per tooth |
538 |
196 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
453 |
282 |
$31K |
| D1120 |
Prophylaxis - child |
659 |
659 |
$28K |
| D1354 |
|
1,191 |
402 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
926 |
925 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
198 |
134 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
616 |
616 |
$17K |
| D1110 |
Prophylaxis - adult |
280 |
279 |
$13K |
| D0274 |
Bitewings - four radiographic images |
678 |
677 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,427 |
1,021 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
334 |
334 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
87 |
68 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,190 |
1,182 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
171 |
166 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
55 |
$3K |
| D4910 |
|
25 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
47 |
47 |
$510.14 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$382.20 |