| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
343 |
203 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
247 |
108 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,137 |
1,121 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
280 |
184 |
$38K |
| D0330 |
Panoramic radiographic image |
373 |
373 |
$35K |
| D1120 |
Prophylaxis - child |
562 |
553 |
$33K |
| D1110 |
Prophylaxis - adult |
407 |
401 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
342 |
338 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
381 |
375 |
$27K |
| D0274 |
Bitewings - four radiographic images |
485 |
481 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
588 |
579 |
$25K |
| D0272 |
Bitewings - two radiographic images |
354 |
352 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
380 |
374 |
$11K |
| D1351 |
Sealant - per tooth |
47 |
14 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$916.00 |