| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
155 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
206 |
120 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
410 |
409 |
$10K |
| D1120 |
Prophylaxis - child |
225 |
225 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
57 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
267 |
266 |
$6K |
| D0274 |
Bitewings - four radiographic images |
115 |
115 |
$4K |
| D1110 |
Prophylaxis - adult |
60 |
60 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
16 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
17 |
$3K |
| D1351 |
Sealant - per tooth |
65 |
17 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
14 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
62 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$936.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
19 |
$780.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
44 |
$510.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$325.00 |