| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,350 |
649 |
$170K |
| D1120 |
Prophylaxis - child |
2,040 |
2,039 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
1,891 |
1,889 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,960 |
1,959 |
$49K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
253 |
144 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
394 |
240 |
$38K |
| D1110 |
Prophylaxis - adult |
456 |
456 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
514 |
513 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,139 |
1,130 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,710 |
953 |
$16K |
| D1351 |
Sealant - per tooth |
496 |
92 |
$15K |
| D0274 |
Bitewings - four radiographic images |
413 |
413 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
159 |
159 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
75 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
157 |
157 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$1K |