| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
265 |
155 |
$27K |
| D1110 |
Prophylaxis - adult |
371 |
370 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
500 |
495 |
$16K |
| D1206 |
Topical application of fluoride varnish |
467 |
463 |
$13K |
| D1120 |
Prophylaxis - child |
319 |
315 |
$12K |
| D0274 |
Bitewings - four radiographic images |
307 |
307 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
202 |
202 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
62 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
599 |
273 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
380 |
372 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
14 |
$3K |
| D0272 |
Bitewings - two radiographic images |
130 |
130 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$2K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$1K |
| D0350 |
|
52 |
51 |
$1K |