| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,244 |
423 |
$85K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
501 |
222 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,291 |
1,263 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
791 |
772 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
567 |
239 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,276 |
1,221 |
$28K |
| D1110 |
Prophylaxis - adult |
859 |
844 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,473 |
2,368 |
$23K |
| D0330 |
Panoramic radiographic image |
699 |
680 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,488 |
2,049 |
$19K |
| D1120 |
Prophylaxis - child |
844 |
842 |
$18K |
| D1351 |
Sealant - per tooth |
890 |
209 |
$15K |
| D1206 |
Topical application of fluoride varnish |
912 |
910 |
$12K |
| D0272 |
Bitewings - two radiographic images |
803 |
796 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
125 |
57 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
225 |
204 |
$5K |
| D4341 |
|
52 |
12 |
$3K |
| D2332 |
|
28 |
12 |
$2K |
| D4921 |
|
54 |
12 |
$402.10 |