| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
990 |
462 |
$149K |
| D1351 |
Sealant - per tooth |
1,783 |
686 |
$112K |
| D1120 |
Prophylaxis - child |
1,482 |
1,479 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,663 |
1,661 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
462 |
274 |
$47K |
| D2332 |
|
320 |
133 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,486 |
1,483 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,355 |
1,351 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
255 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
937 |
932 |
$24K |
| D1110 |
Prophylaxis - adult |
308 |
308 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,931 |
1,909 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,805 |
1,626 |
$10K |
| D4342 |
|
62 |
49 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
89 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
270 |
263 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
28 |
$3K |
| D0272 |
Bitewings - two radiographic images |
199 |
198 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
63 |
$932.63 |
| D9110 |
|
29 |
28 |
$770.00 |
| D2940 |
|
19 |
18 |
$259.90 |