| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
722 |
385 |
$114K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
930 |
736 |
$70K |
| D1120 |
Prophylaxis - child |
1,510 |
1,477 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,201 |
2,147 |
$60K |
| D1110 |
Prophylaxis - adult |
1,083 |
1,075 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,969 |
1,905 |
$47K |
| D0274 |
Bitewings - four radiographic images |
2,225 |
2,163 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,044 |
1,015 |
$27K |
| D1351 |
Sealant - per tooth |
420 |
148 |
$25K |
| D0330 |
Panoramic radiographic image |
1,109 |
1,091 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
915 |
871 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
3,654 |
3,492 |
$21K |
| D9110 |
|
325 |
317 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
256 |
188 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
1,003 |
953 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,053 |
2,677 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
67 |
40 |
$6K |
| D1206 |
Topical application of fluoride varnish |
212 |
208 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
92 |
$5K |
| D0272 |
Bitewings - two radiographic images |
130 |
126 |
$1K |
| D9310 |
|
12 |
12 |
$205.20 |
| D0270 |
|
26 |
26 |
$145.60 |
| D1999 |
|
141 |
122 |
$0.00 |