| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
325 |
184 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
203 |
119 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
915 |
885 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
16 |
$560.00 |
| D1110 |
Prophylaxis - adult |
532 |
504 |
$313.72 |
| D1206 |
Topical application of fluoride varnish |
199 |
181 |
$245.00 |
| D0603 |
|
505 |
474 |
$243.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
522 |
498 |
$217.00 |
| D0220 |
Intraoral - periapical first radiographic image |
547 |
522 |
$200.00 |
| D1120 |
Prophylaxis - child |
317 |
301 |
$172.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
215 |
134 |
$168.00 |
| D0140 |
Limited oral evaluation - problem focused |
318 |
303 |
$124.00 |
| D0274 |
Bitewings - four radiographic images |
248 |
236 |
$96.00 |
| D0210 |
Intraoral - complete series of radiographic images |
163 |
160 |
$95.00 |
| D1330 |
|
856 |
813 |
$60.00 |
| D0120 |
Periodic oral evaluation - established patient |
76 |
59 |
$42.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$0.00 |
| D1310 |
|
301 |
297 |
$0.00 |
| D0601 |
|
194 |
187 |
$0.00 |