| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,092 |
543 |
$116K |
| D1110 |
Prophylaxis - adult |
2,866 |
2,771 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
3,474 |
3,383 |
$90K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
885 |
470 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,641 |
1,554 |
$68K |
| D1120 |
Prophylaxis - child |
2,105 |
2,043 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,724 |
2,638 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,439 |
1,381 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
2,105 |
1,949 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
706 |
674 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,781 |
989 |
$21K |
| D0330 |
Panoramic radiographic image |
352 |
344 |
$17K |
| D0272 |
Bitewings - two radiographic images |
363 |
348 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
50 |
27 |
$5K |
| D1351 |
Sealant - per tooth |
113 |
31 |
$3K |