| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
512 |
259 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
2,982 |
2,883 |
$81K |
| D1120 |
Prophylaxis - child |
1,723 |
1,655 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,516 |
1,457 |
$39K |
| D1110 |
Prophylaxis - adult |
866 |
836 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
568 |
326 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,202 |
1,169 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
853 |
801 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
3,247 |
2,894 |
$19K |
| D0330 |
Panoramic radiographic image |
682 |
637 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,745 |
2,438 |
$12K |
| D9110 |
|
196 |
186 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
463 |
437 |
$8K |
| D4910 |
|
84 |
79 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
38 |
$3K |
| D2330 |
|
27 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
141 |
126 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
56 |
$845.40 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
12 |
12 |
$688.80 |