| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
3,355 |
3,344 |
$116K |
| D1120 |
Prophylaxis - child |
2,690 |
2,681 |
$113K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
898 |
664 |
$68K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,199 |
925 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,808 |
2,798 |
$58K |
| D0330 |
Panoramic radiographic image |
717 |
717 |
$36K |
| D1351 |
Sealant - per tooth |
1,736 |
613 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,404 |
1,400 |
$34K |
| D1110 |
Prophylaxis - adult |
622 |
620 |
$25K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
294 |
236 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
549 |
547 |
$16K |
| D2140 |
|
263 |
217 |
$12K |
| D0272 |
Bitewings - two radiographic images |
538 |
538 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
359 |
356 |
$9K |
| D1354 |
|
263 |
71 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
449 |
443 |
$5K |
| D9992 |
|
328 |
188 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
59 |
$4K |
| D9310 |
|
74 |
74 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
158 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
33 |
33 |
$841.50 |