| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,118 |
830 |
$145K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,596 |
643 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
3,476 |
3,451 |
$82K |
| D1120 |
Prophylaxis - child |
2,404 |
2,388 |
$71K |
| D1206 |
Topical application of fluoride varnish |
3,446 |
3,414 |
$66K |
| D1110 |
Prophylaxis - adult |
1,563 |
1,555 |
$64K |
| D0272 |
Bitewings - two radiographic images |
3,496 |
3,473 |
$56K |
| D7140 |
Extraction, erupted tooth or exposed root |
592 |
413 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
642 |
632 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
558 |
546 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
167 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
358 |
341 |
$4K |
| D2331 |
|
17 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$820.12 |