| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
476 |
194 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
383 |
161 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
364 |
361 |
$13K |
| D1110 |
Prophylaxis - adult |
144 |
144 |
$6K |
| D1120 |
Prophylaxis - child |
148 |
148 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
184 |
184 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
403 |
171 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
262 |
250 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
72 |
72 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
27 |
$992.72 |
| D0120 |
Periodic oral evaluation - established patient |
23 |
23 |
$582.87 |