| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
405 |
175 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
630 |
534 |
$26K |
| D1110 |
Prophylaxis - adult |
435 |
372 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
320 |
257 |
$12K |
| D0274 |
Bitewings - four radiographic images |
314 |
257 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
47 |
28 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
63 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
524 |
376 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
403 |
241 |
$4K |
| D0330 |
Panoramic radiographic image |
71 |
60 |
$3K |
| D1351 |
Sealant - per tooth |
73 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
90 |
78 |
$2K |
| D1120 |
Prophylaxis - child |
55 |
47 |
$2K |
| D1206 |
Topical application of fluoride varnish |
73 |
58 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
26 |
$1K |