| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
770 |
524 |
$89K |
| D0210 |
Intraoral - complete series of radiographic images |
1,218 |
1,184 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,732 |
1,684 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
1,978 |
1,958 |
$60K |
| D7140 |
Extraction, erupted tooth or exposed root |
649 |
399 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,041 |
1,040 |
$30K |
| D1120 |
Prophylaxis - child |
666 |
665 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
291 |
211 |
$26K |
| D1110 |
Prophylaxis - adult |
411 |
410 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,037 |
1,017 |
$16K |
| D1206 |
Topical application of fluoride varnish |
589 |
589 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
290 |
284 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
25 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
587 |
538 |
$5K |
| D4355 |
|
56 |
56 |
$5K |
| D1351 |
Sealant - per tooth |
116 |
12 |
$3K |
| D4341 |
|
29 |
14 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$718.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$350.00 |