| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
932 |
878 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,478 |
1,026 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
625 |
580 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
162 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
997 |
945 |
$25K |
| D0330 |
Panoramic radiographic image |
491 |
456 |
$24K |
| D0274 |
Bitewings - four radiographic images |
707 |
659 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,230 |
1,144 |
$18K |
| D4355 |
|
251 |
234 |
$16K |
| D1206 |
Topical application of fluoride varnish |
963 |
921 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
111 |
82 |
$14K |
| D1120 |
Prophylaxis - child |
445 |
431 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
153 |
104 |
$12K |
| D1351 |
Sealant - per tooth |
269 |
75 |
$7K |
| D0272 |
Bitewings - two radiographic images |
227 |
220 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
25 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
98 |
90 |
$3K |
| D4341 |
|
28 |
12 |
$3K |
| D2332 |
|
20 |
14 |
$2K |
| D2331 |
|
19 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
62 |
61 |
$1K |