| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
602 |
270 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
886 |
886 |
$35K |
| D1110 |
Prophylaxis - adult |
509 |
509 |
$25K |
| D1120 |
Prophylaxis - child |
701 |
701 |
$24K |
| D0274 |
Bitewings - four radiographic images |
797 |
797 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
239 |
108 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
159 |
86 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
859 |
859 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,077 |
1,066 |
$14K |
| D1351 |
Sealant - per tooth |
390 |
109 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
918 |
867 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
39 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
265 |
265 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
67 |
$2K |
| D1206 |
Topical application of fluoride varnish |
70 |
70 |
$1K |