| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,824 |
2,334 |
$566K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,419 |
1,484 |
$218K |
| D1120 |
Prophylaxis - child |
4,894 |
4,891 |
$192K |
| D0120 |
Periodic oral evaluation - established patient |
6,327 |
6,318 |
$166K |
| D1110 |
Prophylaxis - adult |
3,391 |
3,384 |
$164K |
| D1206 |
Topical application of fluoride varnish |
5,857 |
5,856 |
$143K |
| D0274 |
Bitewings - four radiographic images |
3,562 |
3,560 |
$115K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
626 |
419 |
$89K |
| D0140 |
Limited oral evaluation - problem focused |
2,124 |
2,034 |
$86K |
| D0220 |
Intraoral - periapical first radiographic image |
5,314 |
5,180 |
$85K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,900 |
1,899 |
$78K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,426 |
4,529 |
$67K |
| D0240 |
|
1,349 |
676 |
$27K |
| D2750 |
|
29 |
25 |
$17K |
| D0272 |
Bitewings - two radiographic images |
728 |
728 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
137 |
90 |
$11K |
| D1351 |
Sealant - per tooth |
339 |
66 |
$10K |
| D4355 |
|
30 |
30 |
$4K |
| D2950 |
|
14 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
47 |
43 |
$1K |