| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,273 |
1,921 |
$469K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,752 |
879 |
$145K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
968 |
585 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
4,583 |
4,521 |
$123K |
| D1120 |
Prophylaxis - child |
2,962 |
2,926 |
$84K |
| D1110 |
Prophylaxis - adult |
2,148 |
2,118 |
$83K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,755 |
4,699 |
$82K |
| D0220 |
Intraoral - periapical first radiographic image |
2,682 |
2,601 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,156 |
1,138 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,437 |
2,284 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,070 |
1,057 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
448 |
438 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
245 |
235 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
105 |
66 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
37 |
15 |
$6K |
| D0240 |
|
26 |
14 |
$434.46 |