| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
615 |
340 |
$71K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
819 |
324 |
$69K |
| D1120 |
Prophylaxis - child |
365 |
365 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
477 |
477 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
285 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
432 |
432 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
627 |
622 |
$9K |
| D1110 |
Prophylaxis - adult |
179 |
179 |
$9K |
| D0274 |
Bitewings - four radiographic images |
165 |
164 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
584 |
517 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
92 |
90 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$766.86 |