| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
438 |
216 |
$29K |
| D1110 |
Prophylaxis - adult |
420 |
413 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
487 |
472 |
$13K |
| D0274 |
Bitewings - four radiographic images |
347 |
341 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
132 |
82 |
$8K |
| D0330 |
Panoramic radiographic image |
216 |
210 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
125 |
121 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
238 |
235 |
$5K |
| D1206 |
Topical application of fluoride varnish |
186 |
184 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
166 |
164 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
41 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$342.49 |