| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,243 |
2,193 |
$399K |
| D1351 |
Sealant - per tooth |
7,076 |
1,204 |
$200K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,758 |
1,230 |
$164K |
| D1120 |
Prophylaxis - child |
2,562 |
2,557 |
$102K |
| D1110 |
Prophylaxis - adult |
1,844 |
1,829 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
2,885 |
2,872 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,703 |
1,695 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,635 |
2,628 |
$62K |
| D0220 |
Intraoral - periapical first radiographic image |
3,602 |
3,452 |
$58K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
369 |
321 |
$57K |
| D0140 |
Limited oral evaluation - problem focused |
1,169 |
1,139 |
$56K |
| D0274 |
Bitewings - four radiographic images |
1,381 |
1,369 |
$40K |
| D0330 |
Panoramic radiographic image |
505 |
498 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,347 |
2,811 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,096 |
1,093 |
$23K |
| D1206 |
Topical application of fluoride varnish |
447 |
446 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
77 |
$11K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$10K |
| D4341 |
|
32 |
12 |
$6K |
| D0180 |
|
24 |
24 |
$2K |
| D0270 |
|
50 |
42 |
$418.22 |