| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
235 |
123 |
$37K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
386 |
243 |
$36K |
| D1120 |
Prophylaxis - child |
867 |
846 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,375 |
1,327 |
$35K |
| D1110 |
Prophylaxis - adult |
726 |
697 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,167 |
1,117 |
$32K |
| D0330 |
Panoramic radiographic image |
1,087 |
1,047 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
782 |
762 |
$21K |
| D1351 |
Sealant - per tooth |
251 |
109 |
$17K |
| D2740 |
Crown - porcelain/ceramic |
40 |
35 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
2,244 |
1,985 |
$11K |
| D0274 |
Bitewings - four radiographic images |
720 |
673 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,716 |
1,444 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
287 |
254 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
459 |
444 |
$6K |
| D9110 |
|
109 |
104 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
42 |
$3K |
| D0272 |
Bitewings - two radiographic images |
184 |
172 |
$2K |
| D1206 |
Topical application of fluoride varnish |
42 |
42 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0350 |
|
14 |
14 |
$250.00 |