| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
247 |
144 |
$33K |
| D1120 |
Prophylaxis - child |
740 |
727 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
769 |
761 |
$26K |
| D1110 |
Prophylaxis - adult |
427 |
425 |
$25K |
| D1206 |
Topical application of fluoride varnish |
962 |
945 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
445 |
439 |
$21K |
| D0274 |
Bitewings - four radiographic images |
475 |
470 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
152 |
99 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
25 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
298 |
284 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$821.06 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$421.85 |