| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
349 |
170 |
$38K |
| D1120 |
Prophylaxis - child |
590 |
590 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
789 |
789 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
748 |
747 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
950 |
943 |
$15K |
| D1110 |
Prophylaxis - adult |
263 |
263 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,497 |
860 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
93 |
$13K |
| D1351 |
Sealant - per tooth |
396 |
109 |
$12K |
| D0274 |
Bitewings - four radiographic images |
243 |
243 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
157 |
156 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
30 |
$4K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$897.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$600.00 |