| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,138 |
1,136 |
$251K |
| D1110 |
Prophylaxis - adult |
2,675 |
2,669 |
$139K |
| D1120 |
Prophylaxis - child |
3,054 |
3,053 |
$119K |
| D1351 |
Sealant - per tooth |
3,740 |
489 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
3,785 |
3,782 |
$102K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,109 |
2,107 |
$90K |
| D1206 |
Topical application of fluoride varnish |
3,412 |
3,409 |
$84K |
| D0274 |
Bitewings - four radiographic images |
1,979 |
1,978 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
3,732 |
3,701 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
553 |
366 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
351 |
219 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
418 |
416 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,077 |
3,022 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
234 |
67 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
469 |
467 |
$20K |
| D0272 |
Bitewings - two radiographic images |
784 |
783 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
322 |
322 |
$7K |
| D2332 |
|
22 |
13 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$445.60 |
| D1999 |
|
211 |
178 |
$0.00 |