| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
305 |
128 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
263 |
100 |
$15K |
| D1110 |
Prophylaxis - adult |
257 |
237 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
342 |
284 |
$9K |
| D0274 |
Bitewings - four radiographic images |
311 |
290 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
596 |
498 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
529 |
336 |
$5K |
| D1206 |
Topical application of fluoride varnish |
281 |
266 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
157 |
152 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
16 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
58 |
$2K |