| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
440 |
277 |
$29K |
| D1120 |
Prophylaxis - child |
701 |
660 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,254 |
1,175 |
$25K |
| D4341 |
|
107 |
50 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
576 |
539 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
434 |
393 |
$12K |
| D1351 |
Sealant - per tooth |
135 |
56 |
$9K |
| D0274 |
Bitewings - four radiographic images |
487 |
463 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
257 |
238 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
86 |
53 |
$5K |
| D1110 |
Prophylaxis - adult |
139 |
130 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
88 |
62 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
25 |
16 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
98 |
87 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
226 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
14 |
$938.88 |
| D0272 |
Bitewings - two radiographic images |
26 |
25 |
$225.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
46 |
$216.60 |