| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
528 |
241 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
427 |
199 |
$30K |
| D1110 |
Prophylaxis - adult |
542 |
480 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
695 |
529 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
626 |
605 |
$12K |
| D0274 |
Bitewings - four radiographic images |
436 |
392 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
65 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
721 |
557 |
$6K |
| D0330 |
Panoramic radiographic image |
139 |
105 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
305 |
296 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
230 |
211 |
$5K |
| D1120 |
Prophylaxis - child |
129 |
129 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
42 |
$749.06 |