| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
343 |
184 |
$27K |
| D1110 |
Prophylaxis - adult |
257 |
256 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
390 |
390 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
66 |
$10K |
| D1120 |
Prophylaxis - child |
231 |
231 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
236 |
234 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
584 |
561 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
221 |
217 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
269 |
269 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
106 |
104 |
$6K |
| D0274 |
Bitewings - four radiographic images |
180 |
179 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
58 |
$5K |
| D1351 |
Sealant - per tooth |
148 |
34 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
509 |
393 |
$4K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$286.70 |