| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
555 |
265 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
746 |
746 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
315 |
315 |
$20K |
| D1120 |
Prophylaxis - child |
473 |
473 |
$16K |
| D4341 |
|
107 |
31 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
183 |
120 |
$10K |
| D1110 |
Prophylaxis - adult |
228 |
228 |
$10K |
| D0274 |
Bitewings - four radiographic images |
312 |
312 |
$9K |
| D1206 |
Topical application of fluoride varnish |
417 |
417 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
267 |
267 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
27 |
$5K |
| D4346 |
|
40 |
40 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
150 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
65 |
24 |
$4K |
| D0330 |
Panoramic radiographic image |
62 |
62 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
151 |
$2K |