| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,330 |
410 |
$161K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
230 |
148 |
$32K |
| D1120 |
Prophylaxis - child |
686 |
684 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
809 |
801 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
809 |
807 |
$20K |
| D1110 |
Prophylaxis - adult |
272 |
260 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
68 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
144 |
130 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
45 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
439 |
$7K |
| D0274 |
Bitewings - four radiographic images |
185 |
185 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
159 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
514 |
334 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
55 |
$2K |
| D1351 |
Sealant - per tooth |
45 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$625.00 |