| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,850 |
1,364 |
$208K |
| D0120 |
Periodic oral evaluation - established patient |
4,300 |
4,286 |
$144K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,907 |
2,889 |
$144K |
| D1110 |
Prophylaxis - adult |
2,492 |
2,484 |
$140K |
| D1120 |
Prophylaxis - child |
2,959 |
2,952 |
$117K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,671 |
932 |
$116K |
| D0210 |
Intraoral - complete series of radiographic images |
2,033 |
2,016 |
$112K |
| D1351 |
Sealant - per tooth |
3,626 |
604 |
$106K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,213 |
892 |
$102K |
| D1206 |
Topical application of fluoride varnish |
3,110 |
3,103 |
$77K |
| D0274 |
Bitewings - four radiographic images |
2,308 |
2,299 |
$60K |
| D0140 |
Limited oral evaluation - problem focused |
801 |
792 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
2,375 |
2,360 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,548 |
1,350 |
$13K |
| D0272 |
Bitewings - two radiographic images |
343 |
343 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
36 |
$6K |
| D4355 |
|
41 |
41 |
$4K |
| D4341 |
|
25 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
61 |
61 |
$1K |
| D9110 |
|
17 |
17 |
$756.00 |
| D0603 |
|
17 |
17 |
$0.00 |