| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
369 |
163 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
346 |
330 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
96 |
58 |
$12K |
| D1110 |
Prophylaxis - adult |
286 |
282 |
$11K |
| D0330 |
Panoramic radiographic image |
235 |
224 |
$10K |
| D0274 |
Bitewings - four radiographic images |
286 |
279 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
692 |
363 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
47 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
443 |
417 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
158 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
39 |
24 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
118 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
167 |
166 |
$3K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$711.50 |