| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
461 |
240 |
$78K |
| D1120 |
Prophylaxis - child |
532 |
532 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
204 |
159 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
701 |
701 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
706 |
706 |
$18K |
| D1110 |
Prophylaxis - adult |
319 |
319 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
542 |
542 |
$14K |
| D0330 |
Panoramic radiographic image |
550 |
550 |
$14K |
| D1351 |
Sealant - per tooth |
109 |
62 |
$10K |
| D0274 |
Bitewings - four radiographic images |
494 |
494 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
330 |
325 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
565 |
564 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
223 |
223 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
29 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
295 |
295 |
$1K |
| D4910 |
|
15 |
15 |
$1K |