| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
122 |
$25K |
| D1206 |
Topical application of fluoride varnish |
654 |
653 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
134 |
$23K |
| D1110 |
Prophylaxis - adult |
307 |
307 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
459 |
459 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
813 |
803 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
732 |
666 |
$17K |
| D0274 |
Bitewings - four radiographic images |
343 |
343 |
$17K |
| D1120 |
Prophylaxis - child |
340 |
339 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
185 |
$12K |
| D0272 |
Bitewings - two radiographic images |
162 |
161 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
51 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
13 |
$2K |
| D9996 |
|
24 |
24 |
$336.00 |
| D0350 |
|
14 |
14 |
$0.00 |