| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,545 |
649 |
$121K |
| D1110 |
Prophylaxis - adult |
2,656 |
2,203 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
2,466 |
2,187 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,271 |
957 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
735 |
373 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
997 |
713 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,113 |
1,043 |
$21K |
| D1120 |
Prophylaxis - child |
670 |
622 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,373 |
1,091 |
$15K |
| D0272 |
Bitewings - two radiographic images |
608 |
551 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
66 |
$10K |
| D0330 |
Panoramic radiographic image |
214 |
165 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
773 |
625 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
64 |
46 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
128 |
$4K |
| D0274 |
Bitewings - four radiographic images |
84 |
77 |
$2K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$817.12 |