| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
346 |
200 |
$48K |
| D1120 |
Prophylaxis - child |
1,062 |
1,054 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,533 |
1,528 |
$43K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
348 |
200 |
$38K |
| D1351 |
Sealant - per tooth |
693 |
317 |
$37K |
| D4342 |
|
325 |
211 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
476 |
402 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,030 |
1,022 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,359 |
1,353 |
$27K |
| D1110 |
Prophylaxis - adult |
486 |
486 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
860 |
853 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
246 |
221 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
223 |
141 |
$18K |
| D0330 |
Panoramic radiographic image |
577 |
576 |
$16K |
| D9110 |
|
247 |
242 |
$13K |
| D2740 |
Crown - porcelain/ceramic |
46 |
40 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
841 |
799 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,038 |
1,022 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
163 |
142 |
$6K |
| D5110 |
|
13 |
13 |
$6K |
| D2332 |
|
50 |
39 |
$5K |
| D2950 |
|
49 |
47 |
$3K |
| D0272 |
Bitewings - two radiographic images |
288 |
285 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
46 |
$841.28 |
| D4910 |
|
12 |
12 |
$804.00 |