| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
578 |
213 |
$67K |
| D1120 |
Prophylaxis - child |
911 |
911 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,022 |
1,022 |
$26K |
| D1110 |
Prophylaxis - adult |
447 |
447 |
$22K |
| D1206 |
Topical application of fluoride varnish |
565 |
565 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
536 |
536 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
53 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
264 |
264 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
608 |
602 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,058 |
534 |
$9K |
| D0274 |
Bitewings - four radiographic images |
224 |
224 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
15 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$1K |
| D0240 |
|
64 |
32 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$836.80 |