| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
84 |
$16K |
| D1206 |
Topical application of fluoride varnish |
430 |
428 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
399 |
398 |
$14K |
| D1120 |
Prophylaxis - child |
316 |
316 |
$14K |
| D1110 |
Prophylaxis - adult |
88 |
88 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
15 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
13 |
$3K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
68 |
$2K |
| D0272 |
Bitewings - two radiographic images |
60 |
60 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$743.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$493.00 |