| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,546 |
1,017 |
$189K |
| D1351 |
Sealant - per tooth |
5,842 |
1,161 |
$176K |
| D1120 |
Prophylaxis - child |
3,943 |
3,943 |
$160K |
| D1206 |
Topical application of fluoride varnish |
4,416 |
4,416 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
3,953 |
3,953 |
$110K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,333 |
2,586 |
$78K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
445 |
321 |
$64K |
| D0220 |
Intraoral - periapical first radiographic image |
3,020 |
3,003 |
$50K |
| D1110 |
Prophylaxis - adult |
923 |
923 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,072 |
1,072 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
701 |
701 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
294 |
206 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
200 |
194 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
281 |
279 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
14 |
13 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
53 |
37 |
$5K |
| D7111 |
|
49 |
26 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$373.00 |