| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
786 |
472 |
$104K |
| D1110 |
Prophylaxis - adult |
960 |
946 |
$61K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
349 |
245 |
$59K |
| D1206 |
Topical application of fluoride varnish |
1,599 |
1,571 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,110 |
1,087 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
487 |
476 |
$27K |
| D2750 |
|
45 |
37 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
161 |
105 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
267 |
255 |
$12K |
| D0274 |
Bitewings - four radiographic images |
524 |
514 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
167 |
162 |
$9K |
| D1120 |
Prophylaxis - child |
203 |
195 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
24 |
$7K |
| D0330 |
Panoramic radiographic image |
142 |
137 |
$6K |
| D3120 |
|
159 |
116 |
$6K |
| D2394 |
|
27 |
24 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
362 |
345 |
$4K |
| D1330 |
|
393 |
380 |
$2K |
| D0460 |
|
52 |
51 |
$520.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
45 |
$413.28 |