| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,350 |
1,083 |
$198K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,176 |
558 |
$108K |
| D1110 |
Prophylaxis - adult |
2,346 |
1,782 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,337 |
1,761 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,739 |
2,047 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,868 |
1,376 |
$43K |
| D0330 |
Panoramic radiographic image |
1,082 |
741 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,515 |
1,902 |
$32K |
| D1120 |
Prophylaxis - child |
1,492 |
1,121 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,423 |
1,162 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
416 |
222 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,046 |
1,485 |
$23K |
| D2394 |
|
259 |
93 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
607 |
449 |
$17K |
| D2332 |
|
103 |
37 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
45 |
$5K |
| D0272 |
Bitewings - two radiographic images |
334 |
228 |
$4K |
| D1206 |
Topical application of fluoride varnish |
161 |
140 |
$2K |
| D4341 |
|
73 |
12 |
$2K |
| D4355 |
|
26 |
24 |
$2K |
| D9110 |
|
29 |
27 |
$1K |
| D0170 |
|
12 |
12 |
$375.60 |