| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
219 |
109 |
$26K |
| D1120 |
Prophylaxis - child |
444 |
421 |
$17K |
| D1206 |
Topical application of fluoride varnish |
523 |
497 |
$12K |
| D1110 |
Prophylaxis - adult |
246 |
243 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
451 |
437 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
152 |
145 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
243 |
231 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
79 |
40 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
376 |
353 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
114 |
104 |
$4K |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
185 |
99 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$1K |