| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,105 |
531 |
$148K |
| D1110 |
Prophylaxis - adult |
1,551 |
1,538 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
2,401 |
2,376 |
$73K |
| D1120 |
Prophylaxis - child |
1,153 |
1,138 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,131 |
2,106 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,794 |
1,777 |
$42K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
232 |
118 |
$40K |
| D1351 |
Sealant - per tooth |
914 |
195 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
495 |
488 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
577 |
555 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,469 |
2,402 |
$26K |
| D2750 |
|
42 |
29 |
$21K |
| D0330 |
Panoramic radiographic image |
431 |
427 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,190 |
2,150 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
88 |
$16K |
| D1330 |
|
1,024 |
1,016 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
25 |
$6K |
| D2950 |
|
33 |
24 |
$3K |
| D4341 |
|
36 |
13 |
$3K |
| D3120 |
|
23 |
13 |
$805.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$225.00 |