| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
412 |
265 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
343 |
209 |
$36K |
| D7140 |
Extraction, erupted tooth or exposed root |
303 |
119 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
763 |
762 |
$29K |
| D1110 |
Prophylaxis - adult |
494 |
489 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
892 |
889 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
86 |
45 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
363 |
361 |
$12K |
| D0274 |
Bitewings - four radiographic images |
381 |
380 |
$11K |
| D1206 |
Topical application of fluoride varnish |
628 |
625 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
841 |
813 |
$10K |
| D1120 |
Prophylaxis - child |
323 |
323 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
131 |
131 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
263 |
262 |
$6K |
| D0330 |
Panoramic radiographic image |
94 |
94 |
$5K |
| D4342 |
|
51 |
26 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
13 |
$3K |
| D0272 |
Bitewings - two radiographic images |
111 |
111 |
$2K |