| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,640 |
2,266 |
$280K |
| D1110 |
Prophylaxis - adult |
6,032 |
6,031 |
$213K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,349 |
1,966 |
$176K |
| D0120 |
Periodic oral evaluation - established patient |
7,820 |
7,818 |
$137K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,605 |
904 |
$100K |
| D0274 |
Bitewings - four radiographic images |
5,528 |
5,528 |
$86K |
| D2335 |
|
912 |
498 |
$77K |
| D0220 |
Intraoral - periapical first radiographic image |
6,877 |
6,861 |
$65K |
| D1120 |
Prophylaxis - child |
1,967 |
1,966 |
$50K |
| D1351 |
Sealant - per tooth |
1,884 |
530 |
$44K |
| D2332 |
|
671 |
371 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
1,046 |
1,046 |
$38K |
| D2330 |
|
812 |
446 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,313 |
3,312 |
$28K |
| D2331 |
|
456 |
189 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,629 |
2,408 |
$18K |
| D2394 |
|
143 |
116 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
335 |
191 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
523 |
523 |
$12K |
| D0272 |
Bitewings - two radiographic images |
999 |
998 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
245 |
244 |
$2K |
| D4341 |
|
34 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$244.20 |