| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,408 |
678 |
$93K |
| D1351 |
Sealant - per tooth |
3,425 |
1,041 |
$63K |
| D1120 |
Prophylaxis - child |
2,580 |
2,537 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,264 |
1,242 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
704 |
378 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,571 |
1,548 |
$35K |
| D1206 |
Topical application of fluoride varnish |
2,406 |
2,390 |
$29K |
| D0272 |
Bitewings - two radiographic images |
2,011 |
1,972 |
$27K |
| D0274 |
Bitewings - four radiographic images |
292 |
292 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
369 |
344 |
$4K |
| D1110 |
Prophylaxis - adult |
151 |
151 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
186 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
24 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
61 |
$599.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
29 |
$429.00 |