| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
4,763 |
1,376 |
$156K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
4,186 |
2,313 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
7,855 |
7,822 |
$101K |
| D9410 |
|
4,781 |
4,549 |
$64K |
| D1110 |
Prophylaxis - adult |
5,262 |
5,243 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,942 |
2,933 |
$45K |
| D1120 |
Prophylaxis - child |
2,450 |
2,437 |
$30K |
| D9920 |
|
1,129 |
1,105 |
$24K |
| D2330 |
|
851 |
569 |
$23K |
| D1351 |
Sealant - per tooth |
1,797 |
476 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,362 |
1,356 |
$16K |
| D2332 |
|
365 |
263 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,132 |
2,119 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
688 |
687 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
365 |
303 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
457 |
416 |
$6K |
| D5750 |
|
72 |
70 |
$4K |
| D0160 |
|
425 |
396 |
$4K |
| D5110 |
|
13 |
13 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
85 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
12 |
$692.00 |
| D2331 |
|
19 |
13 |
$564.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$63.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$24.00 |
| D0601 |
|
83 |
81 |
$0.00 |
| D0602 |
|
44 |
44 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
45 |
45 |
$0.00 |