| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
429 |
216 |
$40K |
| D1110 |
Prophylaxis - adult |
1,036 |
994 |
$36K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
297 |
109 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,176 |
1,131 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
234 |
121 |
$26K |
| D0330 |
Panoramic radiographic image |
428 |
409 |
$22K |
| D0274 |
Bitewings - four radiographic images |
723 |
692 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,942 |
953 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,330 |
1,236 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
463 |
439 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
494 |
458 |
$16K |
| D1120 |
Prophylaxis - child |
418 |
400 |
$10K |
| D1206 |
Topical application of fluoride varnish |
669 |
630 |
$10K |
| D1351 |
Sealant - per tooth |
253 |
61 |
$6K |
| D4355 |
|
105 |
97 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
44 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
210 |
208 |
$3K |
| D0272 |
Bitewings - two radiographic images |
132 |
123 |
$2K |