| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
409 |
152 |
$39K |
| D1110 |
Prophylaxis - adult |
1,143 |
1,056 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
1,731 |
1,537 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
605 |
537 |
$21K |
| D0274 |
Bitewings - four radiographic images |
778 |
718 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
808 |
786 |
$19K |
| D0330 |
Panoramic radiographic image |
529 |
489 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
153 |
67 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,478 |
1,133 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
187 |
54 |
$11K |
| D1206 |
Topical application of fluoride varnish |
535 |
488 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
209 |
192 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$1K |