| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
1,136 |
652 |
$170K |
| D1351 |
Sealant - per tooth |
2,645 |
1,008 |
$147K |
| D1120 |
Prophylaxis - child |
2,521 |
2,518 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
3,247 |
3,234 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,312 |
2,309 |
$62K |
| D7140 |
Extraction, erupted tooth or exposed root |
656 |
379 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,803 |
1,790 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
804 |
800 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
300 |
204 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,710 |
2,680 |
$18K |
| D1110 |
Prophylaxis - adult |
358 |
357 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,559 |
2,385 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
389 |
380 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
95 |
$5K |
| D1206 |
Topical application of fluoride varnish |
169 |
169 |
$5K |
| D4910 |
|
70 |
70 |
$5K |
| D0272 |
Bitewings - two radiographic images |
403 |
402 |
$4K |
| D4342 |
|
20 |
15 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
27 |
$355.13 |