| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,048 |
509 |
$74K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
302 |
182 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
384 |
200 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
761 |
732 |
$23K |
| D1110 |
Prophylaxis - adult |
436 |
418 |
$17K |
| D0330 |
Panoramic radiographic image |
322 |
306 |
$16K |
| D0274 |
Bitewings - four radiographic images |
890 |
835 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
327 |
314 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
896 |
856 |
$5K |
| D0240 |
|
272 |
131 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
145 |
139 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
782 |
727 |
$4K |
| D1120 |
Prophylaxis - child |
104 |
97 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
25 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
120 |
118 |
$2K |