| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
482 |
216 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
339 |
150 |
$18K |
| D0330 |
Panoramic radiographic image |
547 |
539 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
208 |
70 |
$15K |
| D0274 |
Bitewings - four radiographic images |
479 |
477 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
571 |
563 |
$12K |
| D1110 |
Prophylaxis - adult |
317 |
315 |
$11K |
| D1351 |
Sealant - per tooth |
248 |
33 |
$6K |
| D1310 |
|
436 |
429 |
$5K |
| D1330 |
|
411 |
404 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
45 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
55 |
$3K |
| D1206 |
Topical application of fluoride varnish |
128 |
128 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
333 |
327 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
83 |
$2K |
| D2330 |
|
23 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
117 |
$1K |
| D1320 |
|
33 |
32 |
$629.70 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$347.04 |