| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
536 |
345 |
$54K |
| D1120 |
Prophylaxis - child |
700 |
700 |
$24K |
| D0330 |
Panoramic radiographic image |
422 |
422 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,090 |
1,090 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
875 |
875 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,217 |
1,217 |
$19K |
| D1110 |
Prophylaxis - adult |
394 |
394 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
364 |
361 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
288 |
288 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
145 |
96 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
278 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
13 |
$2K |