| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
642 |
636 |
$24K |
| T1015 |
Clinic visit/encounter, all-inclusive |
135 |
126 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
227 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
942 |
933 |
$18K |
| D1120 |
Prophylaxis - child |
481 |
481 |
$15K |
| D1206 |
Topical application of fluoride varnish |
802 |
800 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
184 |
92 |
$13K |
| D0274 |
Bitewings - four radiographic images |
480 |
477 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
212 |
158 |
$11K |
| D1351 |
Sealant - per tooth |
164 |
28 |
$4K |
| D9110 |
|
128 |
125 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
165 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
39 |
$3K |
| D2330 |
|
63 |
43 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
367 |
362 |
$3K |
| D2331 |
|
39 |
29 |
$3K |
| D0272 |
Bitewings - two radiographic images |
166 |
164 |
$3K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
43 |
$410.45 |