| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
364 |
209 |
$58K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
386 |
243 |
$33K |
| D1120 |
Prophylaxis - child |
722 |
712 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,086 |
1,053 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
804 |
794 |
$22K |
| D0330 |
Panoramic radiographic image |
790 |
773 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
608 |
600 |
$16K |
| D1110 |
Prophylaxis - adult |
177 |
176 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
79 |
$8K |
| D0274 |
Bitewings - four radiographic images |
239 |
234 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
200 |
198 |
$3K |
| D0272 |
Bitewings - two radiographic images |
324 |
315 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
479 |
424 |
$2K |
| D1351 |
Sealant - per tooth |
43 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
73 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
31 |
$152.32 |