| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,013 |
476 |
$63K |
| D0274 |
Bitewings - four radiographic images |
1,272 |
1,210 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
641 |
602 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
858 |
827 |
$20K |
| D1110 |
Prophylaxis - adult |
687 |
657 |
$19K |
| D1351 |
Sealant - per tooth |
1,061 |
154 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
338 |
172 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
208 |
119 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
493 |
467 |
$11K |
| D1120 |
Prophylaxis - child |
517 |
503 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
938 |
895 |
$10K |
| D0350 |
|
364 |
360 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
563 |
528 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
63 |
25 |
$4K |
| D0330 |
Panoramic radiographic image |
85 |
85 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
24 |
$978.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
32 |
$207.88 |