| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,439 |
1,838 |
$286K |
| D1110 |
Prophylaxis - adult |
5,833 |
5,833 |
$237K |
| D1351 |
Sealant - per tooth |
3,116 |
1,019 |
$161K |
| D0274 |
Bitewings - four radiographic images |
5,800 |
5,800 |
$125K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,175 |
1,132 |
$117K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,925 |
4,925 |
$115K |
| D1120 |
Prophylaxis - child |
2,633 |
2,632 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
3,673 |
3,672 |
$84K |
| D0220 |
Intraoral - periapical first radiographic image |
7,805 |
7,797 |
$72K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,662 |
7,657 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,376 |
4,376 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
357 |
301 |
$28K |
| D0272 |
Bitewings - two radiographic images |
997 |
994 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
698 |
679 |
$8K |
| D2954 |
|
66 |
53 |
$7K |
| D2750 |
|
14 |
13 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
93 |
69 |
$5K |
| D2332 |
|
39 |
24 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
502 |
501 |
$2K |
| D1206 |
Topical application of fluoride varnish |
52 |
52 |
$2K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$1K |