| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
536 |
359 |
$39K |
| D1110 |
Prophylaxis - adult |
994 |
992 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
789 |
787 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
635 |
633 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
452 |
451 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
768 |
762 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
911 |
909 |
$7K |
| D1120 |
Prophylaxis - child |
267 |
267 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
105 |
$5K |
| D0274 |
Bitewings - four radiographic images |
296 |
296 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
49 |
$4K |
| D0272 |
Bitewings - two radiographic images |
159 |
159 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
134 |
134 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$758.65 |
| D1206 |
Topical application of fluoride varnish |
35 |
35 |
$572.68 |