| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
571 |
362 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
427 |
274 |
$37K |
| D0330 |
Panoramic radiographic image |
448 |
448 |
$24K |
| D1110 |
Prophylaxis - adult |
550 |
544 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
495 |
495 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
673 |
669 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
739 |
713 |
$5K |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
28 |
$3K |
| D0272 |
Bitewings - two radiographic images |
255 |
255 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
24 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
29 |
$948.68 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
12 |
$147.45 |