| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
395 |
143 |
$20K |
| D1110 |
Prophylaxis - adult |
525 |
519 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
195 |
85 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
396 |
395 |
$8K |
| D9110 |
|
262 |
261 |
$8K |
| D0274 |
Bitewings - four radiographic images |
256 |
254 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
261 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
182 |
182 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
378 |
372 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
258 |
256 |
$2K |
| D1120 |
Prophylaxis - child |
59 |
59 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$1K |
| D2160 |
|
17 |
12 |
$1K |