| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,028 |
861 |
$203K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,041 |
424 |
$123K |
| D7140 |
Extraction, erupted tooth or exposed root |
858 |
335 |
$75K |
| D1110 |
Prophylaxis - adult |
1,747 |
1,704 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
779 |
751 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,024 |
1,007 |
$22K |
| D0274 |
Bitewings - four radiographic images |
808 |
793 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,590 |
1,546 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,329 |
752 |
$6K |
| D2330 |
|
59 |
24 |
$2K |
| D2331 |
|
29 |
12 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
81 |
44 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
42 |
$907.20 |