| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
155 |
$12K |
| D1120 |
Prophylaxis - child |
246 |
245 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
453 |
446 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
134 |
87 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
190 |
137 |
$7K |
| D0274 |
Bitewings - four radiographic images |
386 |
372 |
$6K |
| D1110 |
Prophylaxis - adult |
143 |
137 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
79 |
64 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
714 |
564 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
159 |
147 |
$4K |
| D1206 |
Topical application of fluoride varnish |
165 |
164 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
667 |
642 |
$4K |
| D1351 |
Sealant - per tooth |
13 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
65 |
$1K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$723.20 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$58.20 |