| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
744 |
388 |
$93K |
| D1110 |
Prophylaxis - adult |
1,813 |
1,804 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
3,149 |
3,108 |
$71K |
| D0220 |
Intraoral - periapical first radiographic image |
5,642 |
5,492 |
$68K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,732 |
3,668 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,402 |
1,397 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
394 |
196 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
915 |
913 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
1,019 |
1,012 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
113 |
113 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
24 |
$7K |
| D4342 |
|
44 |
16 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
15 |
$3K |
| D1206 |
Topical application of fluoride varnish |
78 |
78 |
$1K |