| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
395 |
233 |
$48K |
| D1120 |
Prophylaxis - child |
1,138 |
1,138 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,355 |
1,355 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
293 |
178 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
831 |
831 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
415 |
415 |
$18K |
| D1110 |
Prophylaxis - adult |
325 |
325 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
770 |
741 |
$12K |
| D0274 |
Bitewings - four radiographic images |
318 |
318 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
969 |
467 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
110 |
$7K |
| D1351 |
Sealant - per tooth |
87 |
25 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
15 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$883.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
23 |
$480.00 |