| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,331 |
397 |
$102K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,013 |
294 |
$65K |
| D1110 |
Prophylaxis - adult |
646 |
605 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
581 |
542 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
369 |
343 |
$20K |
| D1206 |
Topical application of fluoride varnish |
805 |
756 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
256 |
245 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
252 |
233 |
$8K |
| D0274 |
Bitewings - four radiographic images |
199 |
184 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
247 |
233 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
13 |
$2K |
| D2331 |
|
21 |
12 |
$2K |
| D4341 |
|
42 |
15 |
$2K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |