| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,425 |
522 |
$180K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
650 |
326 |
$100K |
| D1120 |
Prophylaxis - child |
1,243 |
1,243 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,263 |
1,263 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,396 |
1,396 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
357 |
203 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,686 |
1,004 |
$24K |
| D1110 |
Prophylaxis - adult |
438 |
438 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
543 |
537 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,161 |
1,159 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
269 |
263 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
165 |
64 |
$12K |
| D0272 |
Bitewings - two radiographic images |
410 |
410 |
$10K |
| D0274 |
Bitewings - four radiographic images |
143 |
143 |
$5K |
| D7111 |
|
64 |
41 |
$4K |
| D2394 |
|
19 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$730.00 |