| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
441 |
177 |
$59K |
| D1351 |
Sealant - per tooth |
908 |
249 |
$44K |
| D1120 |
Prophylaxis - child |
981 |
969 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,437 |
1,425 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
444 |
288 |
$27K |
| D1110 |
Prophylaxis - adult |
559 |
554 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
878 |
866 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
796 |
784 |
$19K |
| D0274 |
Bitewings - four radiographic images |
956 |
947 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
253 |
145 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
412 |
407 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,406 |
1,383 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,523 |
1,210 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
154 |
105 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
357 |
339 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
39 |
$4K |
| D0272 |
Bitewings - two radiographic images |
114 |
113 |
$1K |
| D2940 |
|
22 |
14 |
$237.30 |