| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
438 |
198 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,023 |
569 |
$63K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
451 |
334 |
$40K |
| D1110 |
Prophylaxis - adult |
730 |
727 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,242 |
1,229 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,101 |
1,092 |
$31K |
| D1120 |
Prophylaxis - child |
719 |
713 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
776 |
769 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
492 |
340 |
$23K |
| D0274 |
Bitewings - four radiographic images |
862 |
851 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
579 |
575 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
680 |
657 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,918 |
1,867 |
$12K |
| D9110 |
|
209 |
207 |
$11K |
| D1351 |
Sealant - per tooth |
213 |
62 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,613 |
1,379 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
45 |
$6K |
| D0330 |
Panoramic radiographic image |
175 |
174 |
$4K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$299.43 |