| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
62 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
25 |
$5K |
| D0274 |
Bitewings - four radiographic images |
137 |
134 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
362 |
344 |
$3K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
304 |
285 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
72 |
68 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
17 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$1K |
| D2331 |
|
19 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
12 |
$236.25 |