| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
971 |
346 |
$132K |
| D1110 |
Prophylaxis - adult |
484 |
484 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
818 |
818 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
899 |
899 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,015 |
929 |
$22K |
| D1120 |
Prophylaxis - child |
480 |
480 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
972 |
969 |
$17K |
| D0274 |
Bitewings - four radiographic images |
447 |
447 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
74 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
16 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$364.00 |