| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,016 |
1,015 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,351 |
1,349 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
482 |
414 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
978 |
977 |
$26K |
| D1351 |
Sealant - per tooth |
356 |
190 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,021 |
1,020 |
$20K |
| D1110 |
Prophylaxis - adult |
366 |
366 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
187 |
172 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
593 |
593 |
$15K |
| D0330 |
Panoramic radiographic image |
446 |
444 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
291 |
250 |
$12K |
| D4341 |
|
70 |
42 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
125 |
79 |
$9K |
| D9110 |
|
149 |
146 |
$8K |
| D2740 |
Crown - porcelain/ceramic |
17 |
14 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
534 |
534 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
661 |
660 |
$4K |
| D0272 |
Bitewings - two radiographic images |
255 |
255 |
$3K |
| D2331 |
|
28 |
27 |
$2K |
| D4342 |
|
24 |
13 |
$2K |
| D2335 |
|
17 |
14 |
$2K |
| D2332 |
|
12 |
12 |
$1K |
| D2950 |
|
13 |
12 |
$942.76 |
| D9630 |
|
12 |
12 |
$282.00 |