| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
756 |
472 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
722 |
467 |
$38K |
| D1110 |
Prophylaxis - adult |
684 |
684 |
$24K |
| D0330 |
Panoramic radiographic image |
493 |
493 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
254 |
184 |
$17K |
| D0274 |
Bitewings - four radiographic images |
624 |
624 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
644 |
644 |
$13K |
| D1351 |
Sealant - per tooth |
492 |
72 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
184 |
104 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
606 |
606 |
$12K |
| D1330 |
|
1,010 |
1,010 |
$11K |
| D1310 |
|
1,016 |
1,016 |
$11K |
| D1206 |
Topical application of fluoride varnish |
557 |
557 |
$10K |
| D1120 |
Prophylaxis - child |
307 |
307 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
165 |
162 |
$9K |
| D2331 |
|
90 |
66 |
$5K |
| D2330 |
|
89 |
59 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
677 |
670 |
$4K |
| D0272 |
Bitewings - two radiographic images |
217 |
217 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
318 |
311 |
$3K |
| D2332 |
|
24 |
15 |
$2K |
| D2394 |
|
17 |
12 |
$1K |
| D2335 |
|
14 |
12 |
$954.20 |
| D9110 |
|
12 |
12 |
$392.54 |