| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
1,204 |
394 |
$172K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,975 |
1,026 |
$152K |
| D1110 |
Prophylaxis - adult |
2,098 |
2,092 |
$99K |
| D1120 |
Prophylaxis - child |
2,180 |
2,179 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
3,101 |
3,095 |
$87K |
| D1206 |
Topical application of fluoride varnish |
2,124 |
2,123 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,142 |
2,136 |
$55K |
| D1351 |
Sealant - per tooth |
733 |
288 |
$50K |
| D0330 |
Panoramic radiographic image |
1,660 |
1,652 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
1,107 |
1,107 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
337 |
281 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
3,091 |
3,081 |
$20K |
| D0274 |
Bitewings - four radiographic images |
989 |
987 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
149 |
124 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,033 |
3,024 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
123 |
83 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
576 |
549 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
105 |
$5K |
| D4342 |
|
17 |
13 |
$3K |
| D4910 |
|
16 |
16 |
$1K |
| D0272 |
Bitewings - two radiographic images |
73 |
73 |
$787.39 |