| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,602 |
924 |
$220K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,797 |
569 |
$173K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,162 |
671 |
$124K |
| D1110 |
Prophylaxis - adult |
1,985 |
1,970 |
$82K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,566 |
1,558 |
$59K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
362 |
264 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
645 |
641 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,704 |
1,689 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
579 |
564 |
$19K |
| D0274 |
Bitewings - four radiographic images |
629 |
623 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,215 |
1,189 |
$15K |
| D0330 |
Panoramic radiographic image |
192 |
191 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
382 |
377 |
$7K |
| D2332 |
|
18 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
67 |
67 |
$2K |
| D2331 |
|
18 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$269.04 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$196.68 |