| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
668 |
443 |
$89K |
| D1120 |
Prophylaxis - child |
1,371 |
1,342 |
$66K |
| D1206 |
Topical application of fluoride varnish |
1,866 |
1,823 |
$60K |
| D0272 |
Bitewings - two radiographic images |
1,624 |
1,593 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,311 |
1,290 |
$54K |
| D1110 |
Prophylaxis - adult |
708 |
692 |
$53K |
| D0330 |
Panoramic radiographic image |
423 |
421 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
415 |
401 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
307 |
288 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
44 |
$12K |
| D0240 |
|
285 |
205 |
$12K |
| D1351 |
Sealant - per tooth |
294 |
99 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
267 |
256 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
111 |
111 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
13 |
$2K |