| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,038 |
576 |
$107K |
| D1110 |
Prophylaxis - adult |
1,753 |
1,617 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,401 |
1,336 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,914 |
1,754 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
529 |
506 |
$34K |
| D1120 |
Prophylaxis - child |
1,006 |
957 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
343 |
204 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
194 |
131 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
642 |
612 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,398 |
1,318 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,566 |
1,461 |
$21K |
| D0274 |
Bitewings - four radiographic images |
724 |
676 |
$19K |
| D2394 |
|
103 |
59 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,067 |
852 |
$13K |
| D0272 |
Bitewings - two radiographic images |
395 |
371 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
305 |
303 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
25 |
$2K |