| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
465 |
175 |
$36K |
| D1110 |
Prophylaxis - adult |
773 |
696 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
512 |
451 |
$28K |
| D1351 |
Sealant - per tooth |
1,345 |
187 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
858 |
759 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
662 |
575 |
$19K |
| D0274 |
Bitewings - four radiographic images |
557 |
500 |
$16K |
| D1206 |
Topical application of fluoride varnish |
942 |
854 |
$12K |
| D7240 |
Removal of impacted tooth - completely bony |
43 |
12 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
948 |
826 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
418 |
362 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
807 |
673 |
$7K |
| D3110 |
|
591 |
137 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
53 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
24 |
$5K |
| D1120 |
Prophylaxis - child |
140 |
120 |
$4K |
| D9248 |
|
42 |
26 |
$2K |
| D9243 |
|
48 |
16 |
$1K |
| D9239 |
|
17 |
16 |
$617.86 |
| D0272 |
Bitewings - two radiographic images |
20 |
12 |
$231.46 |
| D0603 |
|
1,596 |
1,455 |
$0.00 |