| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
426 |
278 |
$55K |
| D0330 |
Panoramic radiographic image |
1,000 |
1,000 |
$50K |
| D1110 |
Prophylaxis - adult |
1,044 |
1,044 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
767 |
767 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
867 |
864 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,168 |
1,166 |
$26K |
| D0274 |
Bitewings - four radiographic images |
895 |
894 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
178 |
83 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
115 |
84 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
815 |
814 |
$10K |
| D1120 |
Prophylaxis - child |
238 |
237 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
77 |
77 |
$891.27 |