| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
979 |
482 |
$125K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,957 |
1,928 |
$105K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
607 |
300 |
$102K |
| D1120 |
Prophylaxis - child |
2,244 |
2,215 |
$102K |
| D1206 |
Topical application of fluoride varnish |
3,705 |
3,659 |
$93K |
| D1110 |
Prophylaxis - adult |
1,383 |
1,366 |
$87K |
| D7140 |
Extraction, erupted tooth or exposed root |
599 |
264 |
$79K |
| D1351 |
Sealant - per tooth |
2,259 |
385 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,306 |
2,279 |
$71K |
| D0140 |
Limited oral evaluation - problem focused |
1,231 |
1,153 |
$57K |
| D0330 |
Panoramic radiographic image |
905 |
904 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
356 |
175 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,492 |
1,476 |
$35K |
| D4341 |
|
244 |
64 |
$19K |
| D1330 |
|
1,893 |
1,868 |
$12K |
| D2394 |
|
51 |
42 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
789 |
751 |
$8K |
| D3120 |
|
77 |
43 |
$3K |
| D0272 |
Bitewings - two radiographic images |
177 |
171 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
155 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
40 |
$919.00 |