| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,254 |
483 |
$155K |
| D1120 |
Prophylaxis - child |
1,580 |
1,575 |
$64K |
| D1206 |
Topical application of fluoride varnish |
1,684 |
1,676 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
444 |
173 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,109 |
1,103 |
$31K |
| D1351 |
Sealant - per tooth |
941 |
197 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
527 |
526 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
903 |
883 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
98 |
57 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,426 |
763 |
$14K |
| D0274 |
Bitewings - four radiographic images |
194 |
192 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
107 |
107 |
$6K |
| D0272 |
Bitewings - two radiographic images |
155 |
154 |
$4K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$646.00 |