| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,000 |
388 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
714 |
333 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
698 |
680 |
$26K |
| D1110 |
Prophylaxis - adult |
622 |
597 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
629 |
607 |
$15K |
| D0330 |
Panoramic radiographic image |
375 |
365 |
$13K |
| D1120 |
Prophylaxis - child |
556 |
535 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
859 |
831 |
$10K |
| D0274 |
Bitewings - four radiographic images |
484 |
475 |
$10K |
| D1351 |
Sealant - per tooth |
455 |
131 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
26 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
117 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
50 |
44 |
$978.00 |
| D0140 |
Limited oral evaluation - problem focused |
41 |
38 |
$907.85 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$193.00 |