| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
656 |
320 |
$77K |
| D1120 |
Prophylaxis - child |
691 |
691 |
$27K |
| D1110 |
Prophylaxis - adult |
497 |
496 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
935 |
935 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
135 |
76 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,029 |
1,008 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
666 |
666 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
162 |
103 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
208 |
207 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,570 |
791 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
334 |
332 |
$13K |
| D0274 |
Bitewings - four radiographic images |
338 |
338 |
$12K |
| D1352 |
|
117 |
37 |
$9K |
| D1351 |
Sealant - per tooth |
284 |
77 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
171 |
$6K |
| D4355 |
|
73 |
73 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
65 |
16 |
$5K |
| D2950 |
|
15 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
103 |
103 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$1K |