| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,710 |
880 |
$218K |
| D1120 |
Prophylaxis - child |
3,187 |
3,182 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
3,803 |
3,795 |
$134K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,317 |
3,308 |
$97K |
| D1110 |
Prophylaxis - adult |
981 |
978 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
492 |
400 |
$48K |
| D0272 |
Bitewings - two radiographic images |
1,502 |
1,498 |
$41K |
| D1351 |
Sealant - per tooth |
1,216 |
337 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
2,036 |
2,030 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,042 |
1,907 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
194 |
152 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
240 |
$15K |
| D0274 |
Bitewings - four radiographic images |
324 |
324 |
$14K |
| D1206 |
Topical application of fluoride varnish |
287 |
287 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
76 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
27 |
$5K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$984.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$645.00 |