| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
541 |
340 |
$66K |
| D1110 |
Prophylaxis - adult |
993 |
993 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,545 |
1,545 |
$41K |
| D1120 |
Prophylaxis - child |
934 |
934 |
$36K |
| D0330 |
Panoramic radiographic image |
480 |
479 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
147 |
121 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
259 |
127 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
492 |
492 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
209 |
147 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
649 |
649 |
$14K |
| D0274 |
Bitewings - four radiographic images |
283 |
283 |
$10K |
| D0272 |
Bitewings - two radiographic images |
364 |
364 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
463 |
444 |
$8K |
| D1206 |
Topical application of fluoride varnish |
217 |
217 |
$5K |
| D4355 |
|
36 |
36 |
$4K |
| D1351 |
Sealant - per tooth |
81 |
28 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
29 |
$459.00 |