| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,239 |
927 |
$230K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
898 |
489 |
$113K |
| D0330 |
Panoramic radiographic image |
1,438 |
1,372 |
$73K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
654 |
274 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,697 |
1,637 |
$71K |
| D0274 |
Bitewings - four radiographic images |
1,967 |
1,899 |
$59K |
| D1110 |
Prophylaxis - adult |
1,521 |
1,491 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
481 |
255 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,413 |
2,287 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,640 |
1,989 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,119 |
1,100 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
686 |
641 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
467 |
453 |
$8K |
| D1206 |
Topical application of fluoride varnish |
233 |
232 |
$4K |
| D2332 |
|
23 |
14 |
$2K |
| D4346 |
|
56 |
56 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$284.60 |