| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,428 |
736 |
$168K |
| D1110 |
Prophylaxis - adult |
944 |
944 |
$45K |
| D1120 |
Prophylaxis - child |
1,115 |
1,115 |
$44K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
291 |
194 |
$41K |
| D1351 |
Sealant - per tooth |
1,248 |
176 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
812 |
812 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,235 |
1,235 |
$32K |
| D1206 |
Topical application of fluoride varnish |
977 |
977 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,407 |
1,391 |
$22K |
| D0274 |
Bitewings - four radiographic images |
494 |
494 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
222 |
222 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
281 |
279 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,358 |
1,338 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
94 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
246 |
246 |
$6K |
| D0272 |
Bitewings - two radiographic images |
191 |
191 |
$4K |
| D2950 |
|
14 |
14 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$2K |