| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
398 |
224 |
$53K |
| D1110 |
Prophylaxis - adult |
1,021 |
1,006 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,181 |
1,167 |
$27K |
| D0274 |
Bitewings - four radiographic images |
629 |
619 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
310 |
309 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
895 |
869 |
$11K |
| D1206 |
Topical application of fluoride varnish |
608 |
601 |
$11K |
| D0330 |
Panoramic radiographic image |
195 |
195 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
554 |
541 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
12 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
143 |
140 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$487.35 |