| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
500 |
191 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
687 |
605 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
581 |
471 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
119 |
$19K |
| D1110 |
Prophylaxis - adult |
197 |
190 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
27 |
$7K |
| D1120 |
Prophylaxis - child |
157 |
140 |
$6K |
| D1206 |
Topical application of fluoride varnish |
208 |
196 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
110 |
88 |
$4K |
| D1351 |
Sealant - per tooth |
45 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
43 |
41 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
28 |
$1K |
| D0274 |
Bitewings - four radiographic images |
20 |
19 |
$588.16 |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
59 |
$447.77 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
12 |
$144.58 |