| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4342 |
|
349 |
86 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
281 |
133 |
$14K |
| D1110 |
Prophylaxis - adult |
294 |
285 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
179 |
171 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
244 |
237 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
337 |
327 |
$5K |
| D0274 |
Bitewings - four radiographic images |
221 |
211 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
243 |
238 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
27 |
$3K |
| D1120 |
Prophylaxis - child |
84 |
83 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
64 |
$1K |
| D1206 |
Topical application of fluoride varnish |
84 |
80 |
$1K |