| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,189 |
1,451 |
$218K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,223 |
899 |
$145K |
| D1110 |
Prophylaxis - adult |
2,710 |
2,707 |
$124K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,294 |
820 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
3,083 |
3,080 |
$78K |
| D1120 |
Prophylaxis - child |
1,828 |
1,826 |
$68K |
| D0274 |
Bitewings - four radiographic images |
2,062 |
2,057 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,527 |
1,525 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
1,522 |
1,467 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
3,804 |
3,692 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,087 |
2,085 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,091 |
2,984 |
$23K |
| D1354 |
|
582 |
165 |
$13K |
| D4355 |
|
139 |
138 |
$12K |
| D0272 |
Bitewings - two radiographic images |
542 |
541 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
164 |
107 |
$10K |
| D1352 |
|
68 |
14 |
$5K |
| D2394 |
|
15 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D0270 |
|
65 |
65 |
$611.37 |