| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
69 |
$16K |
| D1110 |
Prophylaxis - adult |
169 |
169 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
34 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
164 |
164 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
184 |
182 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
274 |
274 |
$6K |
| D0274 |
Bitewings - four radiographic images |
202 |
202 |
$6K |
| D0330 |
Panoramic radiographic image |
94 |
93 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
403 |
388 |
$5K |
| D1120 |
Prophylaxis - child |
103 |
103 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
14 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
15 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
372 |
325 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
84 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
12 |
$638.00 |