| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
189 |
121 |
$14K |
| D1120 |
Prophylaxis - child |
245 |
219 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
280 |
248 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
130 |
90 |
$7K |
| D1110 |
Prophylaxis - adult |
127 |
125 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
144 |
$5K |
| D1351 |
Sealant - per tooth |
51 |
30 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
47 |
$5K |
| D0274 |
Bitewings - four radiographic images |
219 |
200 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
398 |
340 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
59 |
$2K |
| D1206 |
Topical application of fluoride varnish |
80 |
73 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
350 |
295 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
31 |
$846.60 |
| D0272 |
Bitewings - two radiographic images |
69 |
65 |
$601.60 |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
17 |
$301.00 |
| D0602 |
|
20 |
20 |
$220.80 |
| D0330 |
Panoramic radiographic image |
29 |
27 |
$213.00 |