| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
83 |
$20K |
| D1120 |
Prophylaxis - child |
264 |
264 |
$10K |
| D1110 |
Prophylaxis - adult |
201 |
198 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
340 |
339 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
334 |
333 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
181 |
$7K |
| D0274 |
Bitewings - four radiographic images |
181 |
179 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
338 |
333 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
25 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
19 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
306 |
250 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$2K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$312.00 |