| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,125 |
688 |
$113K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
764 |
434 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,078 |
2,016 |
$50K |
| D1110 |
Prophylaxis - adult |
1,373 |
1,321 |
$48K |
| D1120 |
Prophylaxis - child |
1,146 |
1,096 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,916 |
1,857 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
205 |
153 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
649 |
583 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,551 |
1,466 |
$22K |
| D0274 |
Bitewings - four radiographic images |
687 |
664 |
$21K |
| D0330 |
Panoramic radiographic image |
351 |
341 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,367 |
1,248 |
$15K |
| D1351 |
Sealant - per tooth |
395 |
121 |
$11K |
| D0272 |
Bitewings - two radiographic images |
552 |
519 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
286 |
266 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
61 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$1K |
| D4355 |
|
12 |
12 |
$768.48 |