| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
542 |
238 |
$48K |
| D1120 |
Prophylaxis - child |
816 |
792 |
$33K |
| D1351 |
Sealant - per tooth |
698 |
250 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
805 |
780 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
657 |
634 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
489 |
487 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
176 |
128 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,186 |
868 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
990 |
968 |
$7K |
| D0274 |
Bitewings - four radiographic images |
359 |
355 |
$6K |
| D1110 |
Prophylaxis - adult |
118 |
117 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
125 |
120 |
$2K |
| D0272 |
Bitewings - two radiographic images |
167 |
166 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
28 |
$970.82 |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
15 |
$860.64 |
| D9110 |
|
13 |
13 |
$605.00 |
| D0603 |
|
186 |
186 |
$0.00 |