| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,686 |
1,585 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
791 |
585 |
$51K |
| D1351 |
Sealant - per tooth |
668 |
305 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,426 |
1,331 |
$37K |
| D2740 |
Crown - porcelain/ceramic |
145 |
111 |
$37K |
| D4341 |
|
208 |
113 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,514 |
1,441 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
479 |
320 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
622 |
449 |
$28K |
| D1110 |
Prophylaxis - adult |
593 |
571 |
$23K |
| D1206 |
Topical application of fluoride varnish |
901 |
846 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,338 |
1,249 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
3,537 |
3,280 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,233 |
2,642 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
223 |
179 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
623 |
584 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
164 |
135 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
689 |
663 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
351 |
320 |
$9K |
| D0272 |
Bitewings - two radiographic images |
478 |
446 |
$5K |
| D2950 |
|
50 |
42 |
$3K |
| D0330 |
Panoramic radiographic image |
75 |
74 |
$2K |
| D2335 |
|
16 |
12 |
$1K |
| D2331 |
|
19 |
15 |
$1K |
| D2332 |
|
14 |
12 |
$1K |
| D0270 |
|
29 |
29 |
$160.32 |