| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
424 |
289 |
$21K |
| D1110 |
Prophylaxis - adult |
440 |
416 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
961 |
926 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
566 |
551 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
443 |
408 |
$14K |
| D0274 |
Bitewings - four radiographic images |
498 |
473 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
233 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
191 |
121 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
555 |
518 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
71 |
38 |
$6K |
| D0330 |
Panoramic radiographic image |
162 |
156 |
$5K |
| D1120 |
Prophylaxis - child |
123 |
123 |
$3K |
| D4910 |
|
38 |
38 |
$2K |
| D4341 |
|
37 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$760.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$166.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$89.00 |