| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1352 |
|
294 |
72 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
51 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
260 |
259 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
840 |
294 |
$7K |
| D1120 |
Prophylaxis - child |
162 |
160 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
94 |
$6K |
| D4355 |
|
69 |
69 |
$6K |
| D1110 |
Prophylaxis - adult |
119 |
119 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
215 |
213 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
324 |
321 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
33 |
$4K |
| D0274 |
Bitewings - four radiographic images |
110 |
110 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
98 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
57 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
13 |
$2K |