| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
873 |
300 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
749 |
322 |
$52K |
| D1110 |
Prophylaxis - adult |
635 |
537 |
$22K |
| D0274 |
Bitewings - four radiographic images |
723 |
636 |
$20K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
199 |
70 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
628 |
467 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
607 |
542 |
$13K |
| D1206 |
Topical application of fluoride varnish |
741 |
633 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,343 |
665 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,154 |
877 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
27 |
$4K |
| D2332 |
|
26 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
63 |
$2K |
| D2330 |
|
25 |
17 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
36 |
$2K |