| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
232 |
106 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
159 |
81 |
$14K |
| D2332 |
|
75 |
43 |
$9K |
| D1110 |
Prophylaxis - adult |
133 |
131 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
168 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
135 |
133 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
60 |
$6K |
| D1206 |
Topical application of fluoride varnish |
146 |
144 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$361.94 |
| D0330 |
Panoramic radiographic image |
20 |
20 |
$333.50 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$276.93 |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
16 |
$193.23 |