| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
527 |
233 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
246 |
105 |
$11K |
| D1110 |
Prophylaxis - adult |
320 |
319 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
197 |
61 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
334 |
333 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
150 |
150 |
$6K |
| D0274 |
Bitewings - four radiographic images |
164 |
162 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
154 |
154 |
$3K |
| D0330 |
Panoramic radiographic image |
88 |
88 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
458 |
231 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
394 |
383 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
14 |
$1K |