| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
41 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
218 |
218 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
29 |
$9K |
| D0330 |
Panoramic radiographic image |
165 |
165 |
$8K |
| D1110 |
Prophylaxis - adult |
111 |
111 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
53 |
28 |
$7K |
| D1206 |
Topical application of fluoride varnish |
191 |
191 |
$5K |
| D1120 |
Prophylaxis - child |
81 |
81 |
$4K |
| D0272 |
Bitewings - two radiographic images |
206 |
206 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
58 |
$3K |
| D1330 |
|
145 |
145 |
$1K |