| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
485 |
240 |
$36K |
| D1110 |
Prophylaxis - adult |
434 |
406 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
472 |
447 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
110 |
64 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
47 |
$5K |
| D0274 |
Bitewings - four radiographic images |
287 |
264 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
245 |
231 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
137 |
$4K |
| D2950 |
|
16 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
144 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
13 |
$996.55 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$704.90 |
| D1120 |
Prophylaxis - child |
14 |
12 |
$382.20 |