| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
488 |
253 |
$67K |
| D2750 |
|
232 |
148 |
$63K |
| D1351 |
Sealant - per tooth |
906 |
320 |
$45K |
| D1120 |
Prophylaxis - child |
753 |
743 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,030 |
1,015 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
766 |
763 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
263 |
187 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
739 |
729 |
$19K |
| D1110 |
Prophylaxis - adult |
405 |
403 |
$18K |
| D0274 |
Bitewings - four radiographic images |
928 |
917 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,885 |
1,856 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,833 |
1,606 |
$11K |
| D5110 |
|
15 |
15 |
$7K |
| D9110 |
|
122 |
119 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
152 |
113 |
$6K |
| D5120 |
|
14 |
14 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
59 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
297 |
294 |
$6K |
| D0330 |
Panoramic radiographic image |
124 |
124 |
$5K |
| D2950 |
|
69 |
48 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
27 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
37 |
17 |
$3K |
| D0272 |
Bitewings - two radiographic images |
182 |
180 |
$2K |
| D0270 |
|
213 |
208 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$374.53 |