| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
190 |
121 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
180 |
59 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
262 |
262 |
$5K |
| D0350 |
|
394 |
394 |
$5K |
| D0274 |
Bitewings - four radiographic images |
366 |
366 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
206 |
206 |
$4K |
| D1120 |
Prophylaxis - child |
249 |
249 |
$3K |
| D1110 |
Prophylaxis - adult |
200 |
200 |
$3K |
| D1206 |
Topical application of fluoride varnish |
392 |
392 |
$3K |
| D0330 |
Panoramic radiographic image |
187 |
187 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
41 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
289 |
182 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
260 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
76 |
$1K |
| D1351 |
Sealant - per tooth |
66 |
19 |
$997.00 |