| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
426 |
119 |
$65K |
| D4355 |
|
573 |
565 |
$40K |
| D1110 |
Prophylaxis - adult |
1,174 |
1,156 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,673 |
1,656 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
1,274 |
1,225 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
301 |
179 |
$29K |
| D1120 |
Prophylaxis - child |
730 |
730 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
919 |
918 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
678 |
666 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,853 |
1,760 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
386 |
378 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
257 |
116 |
$17K |
| D2332 |
|
187 |
99 |
$16K |
| D2950 |
|
79 |
47 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
150 |
85 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,619 |
1,244 |
$11K |
| D0330 |
Panoramic radiographic image |
107 |
107 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
99 |
52 |
$7K |
| D2335 |
|
73 |
42 |
$7K |
| D0274 |
Bitewings - four radiographic images |
183 |
183 |
$5K |
| D1351 |
Sealant - per tooth |
162 |
45 |
$5K |
| D0272 |
Bitewings - two radiographic images |
188 |
188 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
32 |
$4K |
| D2394 |
|
14 |
12 |
$1K |