| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
245 |
142 |
$20K |
| D1110 |
Prophylaxis - adult |
513 |
512 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
635 |
633 |
$14K |
| D1120 |
Prophylaxis - child |
367 |
366 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
372 |
372 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
108 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
876 |
869 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
426 |
424 |
$8K |
| D0274 |
Bitewings - four radiographic images |
375 |
375 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
973 |
758 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
192 |
192 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
68 |
27 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
99 |
$3K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$646.00 |