| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
540 |
293 |
$36K |
| D1110 |
Prophylaxis - adult |
639 |
619 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
771 |
753 |
$18K |
| D0274 |
Bitewings - four radiographic images |
588 |
578 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
197 |
121 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
460 |
440 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
227 |
218 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
122 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
331 |
320 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
301 |
296 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
489 |
473 |
$4K |
| D1120 |
Prophylaxis - child |
87 |
87 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
17 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
211 |
162 |
$1K |
| D2330 |
|
18 |
12 |
$921.78 |