| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
1,663 |
815 |
$322K |
| D1120 |
Prophylaxis - child |
4,198 |
4,025 |
$168K |
| D1351 |
Sealant - per tooth |
1,754 |
895 |
$136K |
| D0120 |
Periodic oral evaluation - established patient |
4,788 |
4,587 |
$130K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,106 |
3,934 |
$105K |
| D0274 |
Bitewings - four radiographic images |
3,399 |
3,242 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,543 |
2,428 |
$57K |
| D1110 |
Prophylaxis - adult |
952 |
913 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
492 |
381 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
375 |
248 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
5,133 |
4,887 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,553 |
4,339 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
249 |
202 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
820 |
781 |
$15K |
| D9630 |
|
669 |
369 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
229 |
227 |
$8K |
| D0272 |
Bitewings - two radiographic images |
695 |
669 |
$7K |
| D9110 |
|
102 |
100 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$803.25 |
| D4910 |
|
12 |
12 |
$737.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$0.00 |