| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,744 |
1,831 |
$463K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,535 |
1,337 |
$236K |
| D1120 |
Prophylaxis - child |
4,229 |
4,226 |
$167K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,792 |
942 |
$149K |
| D1354 |
|
5,668 |
1,616 |
$119K |
| D1206 |
Topical application of fluoride varnish |
4,417 |
4,414 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
3,612 |
3,611 |
$99K |
| D1351 |
Sealant - per tooth |
3,140 |
1,146 |
$78K |
| D0330 |
Panoramic radiographic image |
1,222 |
1,221 |
$76K |
| D9310 |
|
946 |
946 |
$51K |
| D1110 |
Prophylaxis - adult |
944 |
944 |
$48K |
| D9248 |
|
543 |
500 |
$34K |
| D0274 |
Bitewings - four radiographic images |
581 |
581 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
120 |
99 |
$18K |
| D2330 |
|
217 |
116 |
$17K |
| D0272 |
Bitewings - two radiographic images |
372 |
372 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
83 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
62 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$494.41 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
12 |
$165.00 |