| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
270 |
152 |
$14K |
| D1110 |
Prophylaxis - adult |
270 |
269 |
$9K |
| D0330 |
Panoramic radiographic image |
156 |
154 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
91 |
41 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
194 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
42 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
274 |
273 |
$4K |
| D0274 |
Bitewings - four radiographic images |
226 |
225 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
231 |
231 |
$3K |
| D1120 |
Prophylaxis - child |
153 |
153 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
449 |
275 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
372 |
369 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
65 |
65 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$495.76 |