| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
751 |
422 |
$44K |
| D1110 |
Prophylaxis - adult |
1,274 |
1,271 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,391 |
1,388 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,374 |
1,371 |
$26K |
| D0330 |
Panoramic radiographic image |
543 |
543 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
636 |
635 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
555 |
554 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
145 |
104 |
$7K |
| D1351 |
Sealant - per tooth |
279 |
50 |
$7K |
| D0272 |
Bitewings - two radiographic images |
402 |
401 |
$6K |
| D1120 |
Prophylaxis - child |
170 |
170 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
26 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
439 |
418 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$603.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
17 |
$80.00 |