| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
82 |
$19K |
| D0330 |
Panoramic radiographic image |
330 |
330 |
$16K |
| D1110 |
Prophylaxis - adult |
317 |
317 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
46 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
259 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
259 |
241 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
250 |
250 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
27 |
$5K |
| D0274 |
Bitewings - four radiographic images |
188 |
188 |
$5K |
| D1206 |
Topical application of fluoride varnish |
162 |
161 |
$3K |
| D1120 |
Prophylaxis - child |
81 |
81 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
40 |
$516.86 |