| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,081 |
2,073 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
2,771 |
2,756 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
791 |
660 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,007 |
1,997 |
$53K |
| D1351 |
Sealant - per tooth |
541 |
386 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,830 |
1,822 |
$36K |
| D4341 |
|
210 |
152 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
299 |
269 |
$28K |
| D1110 |
Prophylaxis - adult |
532 |
532 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
892 |
892 |
$23K |
| D0330 |
Panoramic radiographic image |
715 |
711 |
$19K |
| D9110 |
|
220 |
214 |
$12K |
| D4342 |
|
80 |
55 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
197 |
183 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,141 |
1,135 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
853 |
843 |
$7K |
| D0272 |
Bitewings - two radiographic images |
550 |
550 |
$5K |
| D2740 |
Crown - porcelain/ceramic |
14 |
12 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
27 |
$2K |
| D2332 |
|
15 |
14 |
$1K |
| D4910 |
|
13 |
13 |
$842.20 |
| D9630 |
|
36 |
35 |
$799.00 |