| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
130 |
$25K |
| D1110 |
Prophylaxis - adult |
604 |
604 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
75 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
70 |
56 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
149 |
149 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
285 |
$9K |
| D0330 |
Panoramic radiographic image |
138 |
138 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
35 |
$4K |
| D1120 |
Prophylaxis - child |
101 |
101 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
146 |
146 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
116 |
$3K |
| D2394 |
|
16 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
147 |
147 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
75 |
75 |
$2K |