| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,221 |
630 |
$157K |
| D1120 |
Prophylaxis - child |
1,729 |
1,729 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
2,401 |
2,401 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
636 |
358 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,161 |
2,161 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,688 |
2,312 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
2,446 |
2,440 |
$41K |
| D1110 |
Prophylaxis - adult |
726 |
726 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
358 |
209 |
$32K |
| D0274 |
Bitewings - four radiographic images |
596 |
596 |
$22K |
| D1351 |
Sealant - per tooth |
532 |
156 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
113 |
113 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
24 |
$6K |
| D0272 |
Bitewings - two radiographic images |
147 |
147 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$600.00 |