| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
490 |
349 |
$75K |
| D1120 |
Prophylaxis - child |
1,300 |
1,287 |
$54K |
| D1206 |
Topical application of fluoride varnish |
1,647 |
1,636 |
$43K |
| D0272 |
Bitewings - two radiographic images |
1,497 |
1,488 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,138 |
1,132 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
265 |
190 |
$31K |
| D1110 |
Prophylaxis - adult |
539 |
535 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
557 |
550 |
$30K |
| D1351 |
Sealant - per tooth |
468 |
165 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
29 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
166 |
$3K |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
48 |
$2K |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$984.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
31 |
$643.00 |