| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
976 |
404 |
$119K |
| D1120 |
Prophylaxis - child |
1,190 |
1,188 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
475 |
286 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
469 |
212 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,308 |
1,305 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
215 |
131 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,291 |
1,289 |
$30K |
| D1110 |
Prophylaxis - adult |
551 |
548 |
$27K |
| D1351 |
Sealant - per tooth |
929 |
253 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,190 |
1,159 |
$18K |
| D0274 |
Bitewings - four radiographic images |
504 |
501 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
380 |
380 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
344 |
331 |
$13K |
| D2394 |
|
55 |
39 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,071 |
830 |
$9K |
| D0272 |
Bitewings - two radiographic images |
195 |
194 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$420.00 |