| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
856 |
502 |
$55K |
| D0330 |
Panoramic radiographic image |
940 |
938 |
$52K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
876 |
454 |
$43K |
| D1110 |
Prophylaxis - adult |
786 |
784 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
914 |
911 |
$29K |
| D0274 |
Bitewings - four radiographic images |
832 |
831 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
250 |
104 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
161 |
112 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
82 |
59 |
$10K |
| D9110 |
|
156 |
155 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
640 |
630 |
$5K |
| D2335 |
|
43 |
27 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
596 |
302 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
138 |
138 |
$2K |
| D2394 |
|
15 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
16 |
16 |
$962.08 |
| D1206 |
Topical application of fluoride varnish |
50 |
50 |
$747.75 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$221.20 |