| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
457 |
251 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
427 |
241 |
$21K |
| D1110 |
Prophylaxis - adult |
435 |
430 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
587 |
580 |
$12K |
| D1120 |
Prophylaxis - child |
390 |
383 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
531 |
523 |
$10K |
| D0274 |
Bitewings - four radiographic images |
297 |
293 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
126 |
92 |
$8K |
| D0330 |
Panoramic radiographic image |
180 |
176 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
295 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
104 |
103 |
$2K |
| D9110 |
|
49 |
48 |
$1K |
| D2331 |
|
20 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
43 |
$376.00 |