| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
68 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
73 |
$15K |
| D1206 |
Topical application of fluoride varnish |
125 |
121 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
125 |
115 |
$4K |
| D1351 |
Sealant - per tooth |
92 |
27 |
$4K |
| D0330 |
Panoramic radiographic image |
44 |
41 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
152 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
95 |
92 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
58 |
56 |
$3K |
| D0274 |
Bitewings - four radiographic images |
54 |
52 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$3K |
| D1110 |
Prophylaxis - adult |
33 |
30 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
15 |
$1K |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$919.00 |