| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
516 |
211 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
925 |
924 |
$19K |
| D1110 |
Prophylaxis - adult |
506 |
506 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
185 |
87 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
611 |
611 |
$11K |
| D1120 |
Prophylaxis - child |
366 |
366 |
$11K |
| D0274 |
Bitewings - four radiographic images |
374 |
374 |
$10K |
| D1351 |
Sealant - per tooth |
357 |
88 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
47 |
$8K |
| D2330 |
|
139 |
65 |
$7K |
| D1310 |
|
181 |
181 |
$2K |
| D1330 |
|
179 |
179 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
56 |
$448.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$104.00 |