| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
684 |
371 |
$41K |
| D1351 |
Sealant - per tooth |
2,404 |
666 |
$41K |
| D1120 |
Prophylaxis - child |
1,836 |
1,673 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
972 |
909 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,382 |
1,254 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
573 |
297 |
$27K |
| D1206 |
Topical application of fluoride varnish |
2,022 |
1,835 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,151 |
1,049 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,518 |
980 |
$14K |
| D1110 |
Prophylaxis - adult |
397 |
377 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,220 |
1,133 |
$10K |
| D0272 |
Bitewings - two radiographic images |
479 |
432 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
60 |
34 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
215 |
189 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
37 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
69 |
69 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
91 |
$1K |
| D0330 |
Panoramic radiographic image |
102 |
102 |
$1K |
| D0350 |
|
14 |
14 |
$212.00 |