| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,135 |
709 |
$297K |
| D1110 |
Prophylaxis - adult |
1,114 |
1,063 |
$82K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
219 |
180 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
752 |
715 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,020 |
982 |
$44K |
| D1206 |
Topical application of fluoride varnish |
853 |
834 |
$28K |
| D0274 |
Bitewings - four radiographic images |
537 |
507 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
123 |
74 |
$22K |
| D1120 |
Prophylaxis - child |
360 |
356 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
162 |
162 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
704 |
656 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
55 |
$13K |
| D0330 |
Panoramic radiographic image |
101 |
98 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
405 |
347 |
$6K |
| D4355 |
|
31 |
31 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
83 |
$5K |
| D2331 |
|
13 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$461.16 |
| D0603 |
|
261 |
256 |
$0.00 |
| D0602 |
|
128 |
127 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |