| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
986 |
433 |
$132K |
| D1110 |
Prophylaxis - adult |
1,137 |
1,127 |
$74K |
| D1206 |
Topical application of fluoride varnish |
2,334 |
2,306 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,564 |
1,550 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
711 |
699 |
$39K |
| D1120 |
Prophylaxis - child |
864 |
851 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
199 |
122 |
$33K |
| D0330 |
Panoramic radiographic image |
730 |
719 |
$33K |
| D0274 |
Bitewings - four radiographic images |
920 |
910 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
433 |
415 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,015 |
900 |
$11K |
| D7240 |
Removal of impacted tooth - completely bony |
25 |
12 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
29 |
$7K |
| D1330 |
|
681 |
673 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
584 |
546 |
$4K |
| D2332 |
|
24 |
12 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$225.00 |