| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,449 |
1,743 |
$158K |
| D1110 |
Prophylaxis - adult |
3,642 |
3,641 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
5,221 |
5,216 |
$105K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,382 |
1,585 |
$95K |
| D1120 |
Prophylaxis - child |
3,045 |
3,040 |
$91K |
| D0274 |
Bitewings - four radiographic images |
4,079 |
4,079 |
$79K |
| D0220 |
Intraoral - periapical first radiographic image |
5,677 |
5,638 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,196 |
3,194 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,579 |
4,579 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
2,031 |
2,011 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,183 |
1,183 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
1,276 |
1,220 |
$13K |
| D1206 |
Topical application of fluoride varnish |
565 |
563 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
171 |
147 |
$13K |
| D1351 |
Sealant - per tooth |
55 |
27 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
41 |
$2K |
| D2394 |
|
17 |
15 |
$1K |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$788.37 |
| D9110 |
|
25 |
25 |
$387.68 |