| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
654 |
393 |
$102K |
| D1120 |
Prophylaxis - child |
932 |
928 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,176 |
1,157 |
$42K |
| D1110 |
Prophylaxis - adult |
474 |
462 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
108 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
639 |
623 |
$20K |
| D0274 |
Bitewings - four radiographic images |
404 |
402 |
$19K |
| D1206 |
Topical application of fluoride varnish |
713 |
713 |
$16K |
| D0272 |
Bitewings - two radiographic images |
352 |
350 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
189 |
189 |
$11K |
| D0330 |
Panoramic radiographic image |
99 |
99 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
167 |
164 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
259 |
254 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
16 |
$580.00 |