| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,445 |
785 |
$114K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,461 |
766 |
$97K |
| D1120 |
Prophylaxis - child |
2,030 |
1,977 |
$87K |
| D1110 |
Prophylaxis - adult |
2,265 |
2,138 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
3,021 |
2,915 |
$79K |
| D0210 |
Intraoral - complete series of radiographic images |
1,126 |
1,058 |
$72K |
| D0274 |
Bitewings - four radiographic images |
1,779 |
1,717 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,469 |
1,199 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,983 |
1,930 |
$54K |
| D0140 |
Limited oral evaluation - problem focused |
1,273 |
1,165 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
1,125 |
1,040 |
$13K |
| D1351 |
Sealant - per tooth |
319 |
98 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
154 |
66 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
48 |
$6K |
| D2331 |
|
16 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
91 |
63 |
$898.28 |