| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
6,052 |
2,868 |
$454K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,580 |
1,729 |
$197K |
| D1120 |
Prophylaxis - child |
4,511 |
4,194 |
$190K |
| D1206 |
Topical application of fluoride varnish |
5,372 |
5,101 |
$186K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,354 |
841 |
$135K |
| D0120 |
Periodic oral evaluation - established patient |
4,431 |
4,160 |
$91K |
| D1110 |
Prophylaxis - adult |
1,555 |
1,513 |
$62K |
| D0274 |
Bitewings - four radiographic images |
2,585 |
2,452 |
$62K |
| D7140 |
Extraction, erupted tooth or exposed root |
954 |
666 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,079 |
1,024 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
1,030 |
990 |
$26K |
| D1310 |
|
993 |
723 |
$22K |
| D1330 |
|
990 |
721 |
$19K |
| D0330 |
Panoramic radiographic image |
370 |
370 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
756 |
678 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
319 |
228 |
$9K |
| D1351 |
Sealant - per tooth |
186 |
42 |
$4K |
| D0272 |
Bitewings - two radiographic images |
199 |
166 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
83 |
$720.00 |
| D9920 |
|
28 |
26 |
$700.00 |