| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
254 |
128 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
166 |
96 |
$13K |
| D1110 |
Prophylaxis - adult |
248 |
247 |
$10K |
| D0274 |
Bitewings - four radiographic images |
346 |
344 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
55 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
220 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
195 |
193 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
252 |
251 |
$3K |
| D0330 |
Panoramic radiographic image |
130 |
129 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
145 |
142 |
$2K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$712.50 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$166.35 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$149.85 |