| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,437 |
1,139 |
$294K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,613 |
856 |
$147K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
676 |
365 |
$100K |
| D1120 |
Prophylaxis - child |
2,168 |
2,168 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,998 |
2,997 |
$77K |
| D1351 |
Sealant - per tooth |
2,298 |
411 |
$71K |
| D1110 |
Prophylaxis - adult |
1,364 |
1,362 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,597 |
2,597 |
$61K |
| D0274 |
Bitewings - four radiographic images |
1,141 |
1,140 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
356 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,367 |
597 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
668 |
668 |
$11K |
| D2394 |
|
41 |
29 |
$7K |
| D0272 |
Bitewings - two radiographic images |
244 |
244 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
26 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$3K |
| D1206 |
Topical application of fluoride varnish |
83 |
83 |
$2K |