| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
27 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
72 |
$3K |
| D1110 |
Prophylaxis - adult |
85 |
83 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
127 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
109 |
109 |
$2K |
| D1120 |
Prophylaxis - child |
61 |
61 |
$2K |
| D1206 |
Topical application of fluoride varnish |
78 |
78 |
$1K |
| D9110 |
|
46 |
44 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$999.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$975.00 |
| D0274 |
Bitewings - four radiographic images |
38 |
37 |
$892.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$384.00 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
42 |
$324.00 |