| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,850 |
1,397 |
$327K |
| D1120 |
Prophylaxis - child |
6,763 |
6,755 |
$278K |
| D0120 |
Periodic oral evaluation - established patient |
7,072 |
7,064 |
$236K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,863 |
6,853 |
$172K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,850 |
974 |
$168K |
| D9920 |
|
1,169 |
1,122 |
$60K |
| D0272 |
Bitewings - two radiographic images |
2,265 |
2,264 |
$57K |
| D7140 |
Extraction, erupted tooth or exposed root |
689 |
368 |
$54K |
| D1110 |
Prophylaxis - adult |
941 |
941 |
$47K |
| D0240 |
|
1,193 |
717 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,712 |
620 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,020 |
1,017 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
227 |
226 |
$16K |
| D1206 |
Topical application of fluoride varnish |
190 |
190 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
25 |
$5K |
| D0274 |
Bitewings - four radiographic images |
97 |
97 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
54 |
54 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$780.00 |