| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
985 |
389 |
$99K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
357 |
261 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
395 |
214 |
$54K |
| D1110 |
Prophylaxis - adult |
706 |
699 |
$46K |
| D2330 |
|
421 |
165 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
683 |
671 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
407 |
401 |
$23K |
| D0274 |
Bitewings - four radiographic images |
558 |
547 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,169 |
1,064 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
868 |
805 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
80 |
51 |
$10K |
| D0330 |
Panoramic radiographic image |
200 |
200 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
284 |
284 |
$9K |
| D2332 |
|
36 |
20 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
36 |
$2K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$1K |