| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
702 |
277 |
$41K |
| D1351 |
Sealant - per tooth |
1,998 |
288 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
879 |
834 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
381 |
351 |
$18K |
| D1110 |
Prophylaxis - adult |
456 |
441 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
694 |
675 |
$16K |
| D0274 |
Bitewings - four radiographic images |
557 |
535 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
274 |
121 |
$12K |
| D1120 |
Prophylaxis - child |
576 |
557 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
748 |
728 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
805 |
767 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
74 |
36 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
213 |
192 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
601 |
509 |
$5K |
| D0272 |
Bitewings - two radiographic images |
250 |
238 |
$4K |