| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
983 |
368 |
$93K |
| D0210 |
Intraoral - complete series of radiographic images |
755 |
747 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,241 |
1,237 |
$51K |
| D1120 |
Prophylaxis - child |
1,071 |
1,069 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,361 |
1,359 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
896 |
896 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
53 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
494 |
475 |
$8K |
| D1110 |
Prophylaxis - adult |
162 |
160 |
$8K |
| D0274 |
Bitewings - four radiographic images |
80 |
80 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
80 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
91 |
55 |
$871.88 |
| D0272 |
Bitewings - two radiographic images |
30 |
29 |
$699.00 |