| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,120 |
2,114 |
$90K |
| D4341 |
|
590 |
327 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
3,042 |
3,032 |
$85K |
| D1351 |
Sealant - per tooth |
1,274 |
607 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,071 |
921 |
$66K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
689 |
587 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,110 |
2,103 |
$57K |
| D2740 |
Crown - porcelain/ceramic |
192 |
165 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,502 |
2,493 |
$49K |
| D1110 |
Prophylaxis - adult |
1,031 |
1,030 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,564 |
1,559 |
$40K |
| D0330 |
Panoramic radiographic image |
1,185 |
1,182 |
$33K |
| D2332 |
|
285 |
221 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
352 |
200 |
$24K |
| D9110 |
|
416 |
408 |
$23K |
| D4342 |
|
182 |
113 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
375 |
340 |
$15K |
| D2950 |
|
195 |
177 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
101 |
70 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,453 |
1,448 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,860 |
1,842 |
$12K |
| D2335 |
|
96 |
83 |
$9K |
| D2331 |
|
85 |
71 |
$7K |
| D0272 |
Bitewings - two radiographic images |
630 |
629 |
$7K |
| D5110 |
|
14 |
14 |
$6K |
| D3310 |
|
19 |
15 |
$3K |
| D9630 |
|
121 |
119 |
$3K |
| D2394 |
|
18 |
17 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
63 |
$1K |
| D4910 |
|
13 |
13 |
$806.20 |