| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
607 |
347 |
$69K |
| D0210 |
Intraoral - complete series of radiographic images |
939 |
921 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,316 |
1,305 |
$49K |
| D1120 |
Prophylaxis - child |
940 |
940 |
$37K |
| D1351 |
Sealant - per tooth |
1,186 |
300 |
$34K |
| D1110 |
Prophylaxis - adult |
665 |
656 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
230 |
122 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
333 |
133 |
$22K |
| D1206 |
Topical application of fluoride varnish |
797 |
797 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
449 |
438 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
387 |
386 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
665 |
649 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
60 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
193 |
193 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
336 |
272 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
13 |
$3K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$3K |
| D0274 |
Bitewings - four radiographic images |
93 |
93 |
$3K |