| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
367 |
243 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
146 |
104 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
701 |
701 |
$15K |
| D1110 |
Prophylaxis - adult |
308 |
308 |
$14K |
| D1120 |
Prophylaxis - child |
417 |
417 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
714 |
714 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
165 |
127 |
$10K |
| D0330 |
Panoramic radiographic image |
206 |
206 |
$10K |
| D0274 |
Bitewings - four radiographic images |
207 |
207 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
242 |
236 |
$4K |
| D0272 |
Bitewings - two radiographic images |
161 |
161 |
$3K |
| D0240 |
|
104 |
53 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
52 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
129 |
72 |
$982.98 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$457.50 |