| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,496 |
1,514 |
$248K |
| D1120 |
Prophylaxis - child |
6,019 |
6,019 |
$210K |
| D1110 |
Prophylaxis - adult |
3,907 |
3,907 |
$197K |
| D1206 |
Topical application of fluoride varnish |
10,110 |
10,110 |
$166K |
| D0120 |
Periodic oral evaluation - established patient |
7,069 |
7,069 |
$164K |
| D0274 |
Bitewings - four radiographic images |
5,466 |
5,466 |
$150K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,670 |
2,670 |
$109K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
878 |
628 |
$72K |
| D0330 |
Panoramic radiographic image |
1,598 |
1,598 |
$68K |
| D1351 |
Sealant - per tooth |
1,528 |
408 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,994 |
1,994 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
1,720 |
1,703 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
547 |
547 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
383 |
380 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
53 |
$8K |
| D0240 |
|
421 |
226 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
52 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
462 |
312 |
$5K |