| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,200 |
688 |
$81K |
| D1110 |
Prophylaxis - adult |
2,285 |
2,199 |
$80K |
| D0210 |
Intraoral - complete series of radiographic images |
1,216 |
1,167 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,162 |
1,114 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,899 |
1,860 |
$44K |
| D1206 |
Topical application of fluoride varnish |
2,089 |
2,032 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
1,318 |
1,226 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,216 |
1,184 |
$38K |
| D1120 |
Prophylaxis - child |
703 |
692 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
171 |
121 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
189 |
65 |
$13K |
| D2791 |
|
31 |
27 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
183 |
125 |
$11K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
31 |
13 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
836 |
776 |
$9K |
| D2954 |
|
36 |
28 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
25 |
$331.50 |