| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,460 |
798 |
$100K |
| D1120 |
Prophylaxis - child |
2,113 |
2,076 |
$68K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,138 |
770 |
$66K |
| D1110 |
Prophylaxis - adult |
1,442 |
1,414 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,446 |
2,404 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,303 |
1,265 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,749 |
1,728 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,622 |
1,585 |
$31K |
| D0330 |
Panoramic radiographic image |
997 |
963 |
$29K |
| D1206 |
Topical application of fluoride varnish |
652 |
638 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
148 |
101 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
310 |
180 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
345 |
328 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
26 |
$5K |
| D1351 |
Sealant - per tooth |
188 |
57 |
$5K |
| D0272 |
Bitewings - two radiographic images |
426 |
414 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
478 |
433 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
38 |
$89.96 |