| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
910 |
590 |
$80K |
| D1120 |
Prophylaxis - child |
993 |
993 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,362 |
1,362 |
$27K |
| D0274 |
Bitewings - four radiographic images |
879 |
879 |
$25K |
| D1110 |
Prophylaxis - adult |
558 |
558 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,148 |
1,148 |
$17K |
| D0330 |
Panoramic radiographic image |
327 |
327 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,026 |
995 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
484 |
469 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
163 |
92 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
407 |
407 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
39 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
40 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
322 |
290 |
$2K |