| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
24 |
$3K |
| D2394 |
|
25 |
18 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
15 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
18 |
$1K |
| D0274 |
Bitewings - four radiographic images |
78 |
59 |
$1K |
| D1351 |
Sealant - per tooth |
60 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
41 |
36 |
$887.38 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
35 |
$790.50 |
| D0120 |
Periodic oral evaluation - established patient |
23 |
21 |
$187.88 |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
19 |
$180.00 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
17 |
$65.00 |