| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
48 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
848 |
299 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
33 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
295 |
288 |
$5K |
| D1120 |
Prophylaxis - child |
139 |
139 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
213 |
213 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
366 |
360 |
$4K |
| D1110 |
Prophylaxis - adult |
70 |
70 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
159 |
159 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
30 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$1K |