| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
625 |
401 |
$33K |
| D1110 |
Prophylaxis - adult |
802 |
729 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
548 |
305 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
645 |
606 |
$18K |
| D0274 |
Bitewings - four radiographic images |
763 |
702 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
469 |
443 |
$13K |
| D0330 |
Panoramic radiographic image |
426 |
383 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
280 |
198 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
479 |
441 |
$9K |
| D1120 |
Prophylaxis - child |
180 |
160 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
46 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
409 |
382 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
194 |
169 |
$2K |
| D2394 |
|
21 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
12 |
$147.42 |