| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,234 |
1,222 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
729 |
381 |
$43K |
| D1351 |
Sealant - per tooth |
1,746 |
271 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
735 |
282 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,308 |
1,294 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
832 |
820 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
779 |
770 |
$18K |
| D0330 |
Panoramic radiographic image |
496 |
489 |
$18K |
| D9920 |
|
146 |
143 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
180 |
115 |
$12K |
| D1120 |
Prophylaxis - child |
348 |
338 |
$10K |
| D1206 |
Topical application of fluoride varnish |
612 |
600 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,212 |
1,167 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
971 |
946 |
$8K |
| D2332 |
|
91 |
47 |
$6K |
| D9110 |
|
166 |
158 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
67 |
27 |
$4K |
| D2331 |
|
44 |
26 |
$3K |
| D1330 |
|
547 |
536 |
$1K |
| D2335 |
|
18 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$1K |
| D2330 |
|
22 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$784.00 |
| D0602 |
|
125 |
123 |
$520.00 |
| D0601 |
|
61 |
56 |
$440.00 |
| D0603 |
|
47 |
47 |
$260.00 |
| D1310 |
|
147 |
147 |
$95.00 |