| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,650 |
1,163 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,417 |
921 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
2,442 |
2,391 |
$24K |
| D1110 |
Prophylaxis - adult |
2,421 |
2,372 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,805 |
1,783 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
1,371 |
1,344 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,211 |
2,157 |
$14K |
| D0274 |
Bitewings - four radiographic images |
2,091 |
2,050 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
3,305 |
3,193 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
955 |
894 |
$8K |
| D4355 |
|
184 |
182 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
366 |
211 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,347 |
2,308 |
$5K |
| D2750 |
|
12 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
98 |
93 |
$1K |
| D0330 |
Panoramic radiographic image |
87 |
87 |
$929.25 |