| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,658 |
697 |
$111K |
| D1120 |
Prophylaxis - child |
2,428 |
2,428 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,760 |
523 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,521 |
2,521 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,162 |
3,162 |
$38K |
| D0272 |
Bitewings - two radiographic images |
2,542 |
2,541 |
$36K |
| D1110 |
Prophylaxis - adult |
788 |
788 |
$33K |
| D1351 |
Sealant - per tooth |
582 |
201 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
389 |
242 |
$19K |
| D1354 |
|
331 |
119 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
860 |
854 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
358 |
358 |
$8K |
| D9310 |
|
281 |
279 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
257 |
257 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
33 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
466 |
451 |
$3K |
| D2330 |
|
26 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$142.56 |