| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
888 |
399 |
$121K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
632 |
320 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
868 |
868 |
$49K |
| D4341 |
|
507 |
205 |
$45K |
| D1110 |
Prophylaxis - adult |
552 |
552 |
$37K |
| D0330 |
Panoramic radiographic image |
760 |
760 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
77 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
767 |
767 |
$19K |
| D1351 |
Sealant - per tooth |
464 |
66 |
$19K |
| D0274 |
Bitewings - four radiographic images |
682 |
682 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,202 |
1,139 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
968 |
967 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
85 |
44 |
$11K |
| D1120 |
Prophylaxis - child |
151 |
151 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
135 |
135 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |
| D1330 |
|
163 |
163 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$196.92 |