| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D5214 |
|
102 |
102 |
$102K |
| D0330 |
Panoramic radiographic image |
1,532 |
1,429 |
$73K |
| D5213 |
|
65 |
65 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
855 |
357 |
$49K |
| D1110 |
Prophylaxis - adult |
1,127 |
1,037 |
$46K |
| D1351 |
Sealant - per tooth |
2,091 |
431 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,661 |
1,521 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
1,656 |
1,526 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,217 |
1,806 |
$40K |
| D1206 |
Topical application of fluoride varnish |
2,006 |
1,867 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
474 |
254 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,326 |
1,235 |
$30K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
232 |
159 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,502 |
2,247 |
$25K |
| D4355 |
|
395 |
354 |
$15K |
| D1330 |
|
1,688 |
1,547 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
121 |
61 |
$9K |
| D2140 |
|
151 |
64 |
$9K |
| D1120 |
Prophylaxis - child |
283 |
279 |
$8K |
| D2330 |
|
90 |
51 |
$6K |
| D7250 |
|
38 |
13 |
$5K |
| D0272 |
Bitewings - two radiographic images |
134 |
134 |
$4K |
| D2394 |
|
32 |
30 |
$3K |
| D2161 |
|
18 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
246 |
246 |
$1K |
| D9995 |
|
14 |
12 |
$0.00 |