| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
389 |
199 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
254 |
163 |
$17K |
| D1120 |
Prophylaxis - child |
524 |
521 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
433 |
432 |
$9K |
| D0274 |
Bitewings - four radiographic images |
429 |
426 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,270 |
733 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
213 |
212 |
$7K |
| D9430 |
|
240 |
230 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
616 |
613 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
46 |
$4K |
| D1110 |
Prophylaxis - adult |
89 |
89 |
$3K |
| D1351 |
Sealant - per tooth |
157 |
56 |
$3K |
| D0350 |
|
491 |
263 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
316 |
297 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
30 |
25 |
$2K |
| D0330 |
Panoramic radiographic image |
78 |
78 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$2K |
| D2330 |
|
17 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
81 |
81 |
$810.00 |