| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,307 |
644 |
$231K |
| D2332 |
|
302 |
112 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
768 |
670 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
792 |
765 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
617 |
616 |
$19K |
| D1110 |
Prophylaxis - adult |
276 |
276 |
$18K |
| D1120 |
Prophylaxis - child |
354 |
353 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
647 |
647 |
$15K |
| D9248 |
|
63 |
62 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
103 |
41 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
795 |
766 |
$8K |
| D0274 |
Bitewings - four radiographic images |
305 |
305 |
$7K |
| D0272 |
Bitewings - two radiographic images |
346 |
346 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$3K |
| D1330 |
|
393 |
392 |
$2K |
| D0460 |
|
99 |
91 |
$970.00 |
| D3120 |
|
21 |
18 |
$695.00 |