| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
256 |
149 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
182 |
103 |
$22K |
| D1110 |
Prophylaxis - adult |
174 |
173 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
172 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
27 |
$8K |
| D0330 |
Panoramic radiographic image |
95 |
94 |
$8K |
| D0274 |
Bitewings - four radiographic images |
222 |
220 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
181 |
180 |
$6K |
| D0240 |
|
261 |
139 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
36 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
135 |
135 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
235 |
$2K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
163 |
161 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |