| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
782 |
446 |
$52K |
| D0330 |
Panoramic radiographic image |
793 |
776 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
399 |
261 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
458 |
269 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
531 |
519 |
$15K |
| D1120 |
Prophylaxis - child |
252 |
244 |
$14K |
| D1110 |
Prophylaxis - adult |
252 |
248 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
406 |
395 |
$12K |
| D0274 |
Bitewings - four radiographic images |
280 |
278 |
$9K |
| D1206 |
Topical application of fluoride varnish |
525 |
511 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
72 |
$5K |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
77 |
77 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
216 |
$2K |
| D1351 |
Sealant - per tooth |
45 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
12 |
$120.12 |