| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
693 |
420 |
$103K |
| D1120 |
Prophylaxis - child |
2,140 |
2,102 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
2,872 |
2,839 |
$79K |
| D1351 |
Sealant - per tooth |
1,095 |
560 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,072 |
2,037 |
$53K |
| D0274 |
Bitewings - four radiographic images |
2,485 |
2,460 |
$49K |
| D4342 |
|
418 |
308 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,727 |
1,703 |
$42K |
| D1110 |
Prophylaxis - adult |
884 |
880 |
$42K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
454 |
278 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
541 |
312 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
575 |
505 |
$34K |
| D0330 |
Panoramic radiographic image |
1,079 |
1,068 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
287 |
239 |
$21K |
| D9110 |
|
345 |
332 |
$19K |
| D2332 |
|
192 |
156 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,818 |
1,606 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,981 |
1,934 |
$13K |
| D0272 |
Bitewings - two radiographic images |
698 |
686 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
147 |
136 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
98 |
98 |
$2K |
| D2335 |
|
22 |
13 |
$2K |
| D2950 |
|
12 |
12 |
$754.65 |