| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
307 |
137 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
826 |
801 |
$19K |
| D1110 |
Prophylaxis - adult |
489 |
469 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
149 |
78 |
$14K |
| D1120 |
Prophylaxis - child |
492 |
476 |
$12K |
| D1206 |
Topical application of fluoride varnish |
632 |
606 |
$9K |
| D0274 |
Bitewings - four radiographic images |
263 |
250 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
181 |
170 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
125 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
361 |
327 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
355 |
164 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
142 |
134 |
$2K |
| D1351 |
Sealant - per tooth |
58 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
25 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$440.16 |