| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
515 |
309 |
$71K |
| D1110 |
Prophylaxis - adult |
1,197 |
1,189 |
$49K |
| D0330 |
Panoramic radiographic image |
612 |
610 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
758 |
749 |
$29K |
| D0274 |
Bitewings - four radiographic images |
916 |
906 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
286 |
87 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
826 |
812 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
508 |
496 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
100 |
$17K |
| D1120 |
Prophylaxis - child |
341 |
334 |
$11K |
| D1206 |
Topical application of fluoride varnish |
593 |
584 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
669 |
652 |
$8K |
| D2950 |
|
16 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
58 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
35 |
$670.00 |