| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
526 |
526 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
504 |
504 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
122 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
344 |
344 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
714 |
706 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
154 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
589 |
588 |
$4K |
| D0274 |
Bitewings - four radiographic images |
192 |
192 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
68 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
146 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
131 |
131 |
$1K |