| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4342 |
|
751 |
260 |
$63K |
| D1351 |
Sealant - per tooth |
720 |
366 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,860 |
1,675 |
$49K |
| D1120 |
Prophylaxis - child |
962 |
873 |
$35K |
| D4341 |
|
176 |
62 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
315 |
168 |
$23K |
| D1110 |
Prophylaxis - adult |
625 |
605 |
$23K |
| D1206 |
Topical application of fluoride varnish |
876 |
791 |
$20K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
217 |
148 |
$19K |
| D0274 |
Bitewings - four radiographic images |
1,076 |
992 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,819 |
1,576 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
358 |
317 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,733 |
1,513 |
$6K |
| D0330 |
Panoramic radiographic image |
371 |
339 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
246 |
243 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
41 |
$3K |
| D0272 |
Bitewings - two radiographic images |
213 |
203 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
18 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
40 |
$615.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
14 |
$390.00 |
| D1999 |
|
80 |
77 |
$0.00 |