| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
422 |
255 |
$45K |
| D1120 |
Prophylaxis - child |
665 |
663 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
808 |
808 |
$21K |
| D1110 |
Prophylaxis - adult |
392 |
392 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,075 |
1,036 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
408 |
407 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
97 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
342 |
331 |
$13K |
| D1351 |
Sealant - per tooth |
406 |
116 |
$11K |
| D0274 |
Bitewings - four radiographic images |
312 |
312 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
345 |
344 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
919 |
780 |
$8K |
| D1206 |
Topical application of fluoride varnish |
397 |
394 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
90 |
$5K |
| D0330 |
Panoramic radiographic image |
87 |
87 |
$5K |
| D0272 |
Bitewings - two radiographic images |
170 |
170 |
$4K |
| D4910 |
|
34 |
33 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
17 |
$1K |
| D1330 |
|
38 |
38 |
$0.00 |
| D0602 |
|
22 |
22 |
$0.00 |