| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
329 |
187 |
$17K |
| D0274 |
Bitewings - four radiographic images |
826 |
806 |
$14K |
| D1110 |
Prophylaxis - adult |
534 |
521 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
660 |
642 |
$13K |
| D1120 |
Prophylaxis - child |
602 |
589 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,628 |
1,569 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
280 |
141 |
$11K |
| D1206 |
Topical application of fluoride varnish |
837 |
822 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,938 |
1,381 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
238 |
89 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
622 |
615 |
$9K |
| D1351 |
Sealant - per tooth |
321 |
46 |
$5K |
| D0272 |
Bitewings - two radiographic images |
417 |
406 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
201 |
$3K |
| D1999 |
|
235 |
201 |
$0.00 |