| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
633 |
502 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
716 |
539 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
754 |
754 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
1,185 |
1,098 |
$17K |
| D1120 |
Prophylaxis - child |
1,182 |
1,180 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,625 |
1,623 |
$16K |
| D1110 |
Prophylaxis - adult |
708 |
706 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
435 |
435 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
644 |
643 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,562 |
1,531 |
$6K |
| D0274 |
Bitewings - four radiographic images |
645 |
645 |
$6K |
| D1351 |
Sealant - per tooth |
556 |
175 |
$6K |
| D0603 |
|
541 |
541 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
111 |
$4K |
| D2335 |
|
72 |
55 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
86 |
84 |
$4K |
| D4341 |
|
99 |
57 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
965 |
962 |
$3K |
| D0602 |
|
172 |
172 |
$2K |
| D2330 |
|
48 |
40 |
$2K |
| D9910 |
|
335 |
335 |
$2K |
| D2331 |
|
38 |
29 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
59 |
59 |
$885.00 |
| D0270 |
|
254 |
248 |
$762.00 |
| D1320 |
|
47 |
47 |
$470.00 |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$410.00 |
| D1352 |
|
33 |
26 |
$330.00 |
| D0601 |
|
30 |
30 |
$300.00 |
| D2940 |
|
12 |
12 |
$67.00 |
| D1999 |
|
254 |
184 |
$0.00 |