| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,560 |
6,560 |
$331K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,753 |
1,204 |
$185K |
| D0120 |
Periodic oral evaluation - established patient |
7,864 |
7,864 |
$183K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,879 |
9,879 |
$162K |
| D1120 |
Prophylaxis - child |
3,246 |
3,246 |
$113K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,286 |
935 |
$108K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,674 |
1,674 |
$68K |
| D0330 |
Panoramic radiographic image |
1,194 |
1,194 |
$60K |
| D0272 |
Bitewings - two radiographic images |
2,964 |
2,964 |
$56K |
| D0274 |
Bitewings - four radiographic images |
1,887 |
1,887 |
$53K |
| D1351 |
Sealant - per tooth |
153 |
44 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
48 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
85 |
$1K |