| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,044 |
454 |
$122K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
510 |
277 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
321 |
169 |
$29K |
| D1120 |
Prophylaxis - child |
807 |
806 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,092 |
1,092 |
$23K |
| D1110 |
Prophylaxis - adult |
586 |
584 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,604 |
1,538 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
195 |
194 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
776 |
776 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,097 |
1,309 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
427 |
425 |
$10K |
| D0274 |
Bitewings - four radiographic images |
771 |
761 |
$7K |
| D1352 |
|
94 |
26 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
479 |
470 |
$5K |
| D1206 |
Topical application of fluoride varnish |
191 |
191 |
$4K |
| D1351 |
Sealant - per tooth |
96 |
26 |
$3K |
| D4355 |
|
31 |
31 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
186 |
122 |
$0.00 |
| D0330 |
Panoramic radiographic image |
436 |
423 |
$0.00 |