| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
266 |
141 |
$42K |
| D1120 |
Prophylaxis - child |
989 |
934 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
415 |
298 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,544 |
1,478 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,122 |
1,073 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
642 |
605 |
$18K |
| D1206 |
Topical application of fluoride varnish |
677 |
633 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
807 |
783 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,936 |
1,850 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,368 |
1,067 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
127 |
66 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
94 |
67 |
$7K |
| D1351 |
Sealant - per tooth |
23 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
25 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D9110 |
|
13 |
13 |
$715.00 |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$265.79 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$112.80 |