| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,543 |
222 |
$158K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
532 |
107 |
$51K |
| D1110 |
Prophylaxis - adult |
410 |
389 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
219 |
214 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
324 |
316 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
109 |
38 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
396 |
375 |
$13K |
| D2394 |
|
88 |
46 |
$13K |
| D1120 |
Prophylaxis - child |
283 |
277 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
59 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
214 |
208 |
$9K |
| D1206 |
Topical application of fluoride varnish |
311 |
303 |
$9K |
| D0274 |
Bitewings - four radiographic images |
253 |
242 |
$9K |
| D1320 |
|
179 |
173 |
$5K |
| D1321 |
|
181 |
174 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
267 |
253 |
$3K |
| D0272 |
Bitewings - two radiographic images |
82 |
80 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
44 |
$599.63 |