| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,433 |
551 |
$94K |
| D1110 |
Prophylaxis - adult |
1,005 |
994 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,289 |
1,275 |
$85K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
862 |
344 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
765 |
761 |
$61K |
| D1120 |
Prophylaxis - child |
788 |
783 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
795 |
786 |
$38K |
| D1206 |
Topical application of fluoride varnish |
2,024 |
2,006 |
$34K |
| D1351 |
Sealant - per tooth |
436 |
123 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
749 |
723 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,924 |
876 |
$8K |
| D0274 |
Bitewings - four radiographic images |
340 |
336 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
56 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
12 |
$2K |