| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
376 |
169 |
$44K |
| D1120 |
Prophylaxis - child |
564 |
564 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
696 |
694 |
$18K |
| D1110 |
Prophylaxis - adult |
347 |
344 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
667 |
667 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
60 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
256 |
254 |
$10K |
| D0274 |
Bitewings - four radiographic images |
199 |
199 |
$6K |
| D0330 |
Panoramic radiographic image |
64 |
64 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$902.00 |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
43 |
$658.48 |