| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
673 |
386 |
$63K |
| D1110 |
Prophylaxis - adult |
1,026 |
1,024 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
504 |
261 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,416 |
1,412 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
563 |
561 |
$28K |
| D1120 |
Prophylaxis - child |
700 |
700 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
622 |
190 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
743 |
739 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,191 |
1,173 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
599 |
599 |
$12K |
| D0274 |
Bitewings - four radiographic images |
470 |
470 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,711 |
930 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
424 |
409 |
$9K |
| D1206 |
Topical application of fluoride varnish |
262 |
262 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
27 |
$3K |
| D0272 |
Bitewings - two radiographic images |
88 |
88 |
$2K |
| D1351 |
Sealant - per tooth |
58 |
14 |
$2K |
| D4355 |
|
12 |
12 |
$475.34 |