| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,049 |
527 |
$54K |
| D1110 |
Prophylaxis - adult |
1,170 |
1,143 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,746 |
1,707 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,290 |
1,259 |
$23K |
| D1120 |
Prophylaxis - child |
1,175 |
1,150 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
772 |
750 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,372 |
1,339 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,040 |
1,545 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
245 |
144 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
217 |
122 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,826 |
1,735 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
47 |
$858.04 |