| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,060 |
535 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
394 |
189 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
479 |
475 |
$17K |
| D1120 |
Prophylaxis - child |
442 |
439 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
154 |
104 |
$13K |
| D1110 |
Prophylaxis - adult |
237 |
235 |
$10K |
| D0274 |
Bitewings - four radiographic images |
350 |
348 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
521 |
518 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
162 |
157 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
203 |
199 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
197 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
15 |
$813.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
27 |
$414.50 |