| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,522 |
1,239 |
$167K |
| D0120 |
Periodic oral evaluation - established patient |
5,626 |
5,614 |
$143K |
| D1110 |
Prophylaxis - adult |
3,071 |
3,066 |
$122K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,188 |
993 |
$114K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,504 |
5,495 |
$93K |
| D1120 |
Prophylaxis - child |
2,952 |
2,946 |
$70K |
| D1351 |
Sealant - per tooth |
2,826 |
1,063 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
7,249 |
7,104 |
$60K |
| D0272 |
Bitewings - two radiographic images |
5,448 |
5,438 |
$55K |
| D0330 |
Panoramic radiographic image |
1,044 |
1,043 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,979 |
6,279 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
1,060 |
1,016 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
301 |
300 |
$11K |
| D1999 |
|
2,275 |
2,043 |
$11K |
| D9630 |
|
219 |
219 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
43 |
28 |
$3K |
| D0274 |
Bitewings - four radiographic images |
108 |
107 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$980.05 |
| D9999 |
Unspecified adjunctive procedure, by report |
29 |
29 |
$799.82 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$280.92 |