| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,727 |
1,216 |
$162K |
| D1110 |
Prophylaxis - adult |
2,464 |
2,464 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
3,571 |
3,571 |
$79K |
| D1120 |
Prophylaxis - child |
2,252 |
2,252 |
$74K |
| D0274 |
Bitewings - four radiographic images |
2,860 |
2,860 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,204 |
3,204 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
376 |
320 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
2,869 |
2,843 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
924 |
924 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
973 |
971 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,207 |
2,050 |
$33K |
| D0330 |
Panoramic radiographic image |
594 |
594 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
369 |
279 |
$27K |
| D0272 |
Bitewings - two radiographic images |
782 |
782 |
$15K |
| D1206 |
Topical application of fluoride varnish |
501 |
501 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
25 |
$3K |
| D1351 |
Sealant - per tooth |
85 |
30 |
$2K |