| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,103 |
596 |
$125K |
| D1120 |
Prophylaxis - child |
2,474 |
2,472 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
3,156 |
3,153 |
$79K |
| D1206 |
Topical application of fluoride varnish |
2,736 |
2,734 |
$63K |
| D1110 |
Prophylaxis - adult |
1,076 |
1,075 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
295 |
295 |
$12K |
| D0274 |
Bitewings - four radiographic images |
289 |
289 |
$9K |
| D0272 |
Bitewings - two radiographic images |
380 |
380 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
38 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
378 |
372 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
24 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
70 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
207 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$240.00 |