| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
7,662 |
6,277 |
$265K |
| D1120 |
Prophylaxis - child |
5,464 |
4,568 |
$230K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,556 |
679 |
$116K |
| D1110 |
Prophylaxis - adult |
2,856 |
2,293 |
$114K |
| D0274 |
Bitewings - four radiographic images |
3,640 |
2,968 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
3,418 |
2,623 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,234 |
476 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,824 |
1,582 |
$55K |
| D0330 |
Panoramic radiographic image |
888 |
833 |
$44K |
| D2740 |
Crown - porcelain/ceramic |
28 |
25 |
$14K |
| D1310 |
|
465 |
405 |
$10K |
| D1330 |
|
476 |
409 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
661 |
583 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
284 |
249 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
274 |
236 |
$7K |
| D1351 |
Sealant - per tooth |
301 |
86 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
25 |
$5K |
| D0272 |
Bitewings - two radiographic images |
261 |
256 |
$5K |
| D2950 |
|
30 |
24 |
$3K |
| D9920 |
|
13 |
13 |
$325.00 |