| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
522 |
260 |
$71K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
629 |
401 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
476 |
305 |
$29K |
| D1120 |
Prophylaxis - child |
567 |
564 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
883 |
870 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
790 |
781 |
$22K |
| D0330 |
Panoramic radiographic image |
784 |
769 |
$18K |
| D1110 |
Prophylaxis - adult |
355 |
351 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
491 |
491 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
149 |
60 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
278 |
277 |
$6K |
| D0272 |
Bitewings - two radiographic images |
634 |
625 |
$6K |
| D5110 |
|
12 |
12 |
$5K |
| D0274 |
Bitewings - four radiographic images |
309 |
301 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
38 |
$5K |
| D1351 |
Sealant - per tooth |
44 |
18 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
463 |
430 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
40 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
73 |
$1K |