| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,036 |
559 |
$118K |
| D1120 |
Prophylaxis - child |
2,095 |
2,095 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
717 |
413 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
2,389 |
2,387 |
$63K |
| D1206 |
Topical application of fluoride varnish |
2,335 |
2,333 |
$53K |
| D1110 |
Prophylaxis - adult |
820 |
819 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
293 |
293 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
450 |
449 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
933 |
926 |
$14K |
| D0274 |
Bitewings - four radiographic images |
356 |
356 |
$12K |
| D0272 |
Bitewings - two radiographic images |
161 |
161 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
455 |
442 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$2K |