| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,113 |
693 |
$126K |
| D1120 |
Prophylaxis - child |
1,657 |
1,655 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,353 |
2,350 |
$58K |
| D1110 |
Prophylaxis - adult |
1,145 |
1,144 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,886 |
1,883 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
180 |
126 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
271 |
271 |
$19K |
| D0274 |
Bitewings - four radiographic images |
581 |
581 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
185 |
131 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
513 |
502 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
173 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
169 |
167 |
$6K |
| D1206 |
Topical application of fluoride varnish |
166 |
166 |
$4K |
| D0272 |
Bitewings - two radiographic images |
91 |
91 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$137.06 |