| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,165 |
978 |
$165K |
| D1110 |
Prophylaxis - adult |
3,876 |
3,831 |
$136K |
| D0274 |
Bitewings - four radiographic images |
4,490 |
4,438 |
$122K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,018 |
1,008 |
$121K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,621 |
389 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
3,435 |
3,415 |
$72K |
| D0330 |
Panoramic radiographic image |
2,030 |
1,985 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,086 |
2,037 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,752 |
1,727 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
558 |
367 |
$29K |
| D1120 |
Prophylaxis - child |
952 |
939 |
$28K |
| D2740 |
Crown - porcelain/ceramic |
41 |
33 |
$26K |
| D0272 |
Bitewings - two radiographic images |
714 |
704 |
$11K |
| D5110 |
|
13 |
13 |
$7K |
| D5120 |
|
12 |
12 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
98 |
75 |
$6K |
| D2331 |
|
84 |
49 |
$5K |
| D2330 |
|
85 |
43 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
393 |
390 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
89 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
76 |
71 |
$576.00 |