| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,289 |
509 |
$175K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,545 |
528 |
$162K |
| D1110 |
Prophylaxis - adult |
769 |
762 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
731 |
722 |
$40K |
| D0330 |
Panoramic radiographic image |
739 |
731 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
649 |
548 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
153 |
81 |
$26K |
| D1206 |
Topical application of fluoride varnish |
823 |
816 |
$21K |
| D0274 |
Bitewings - four radiographic images |
775 |
769 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
725 |
649 |
$8K |
| D2330 |
|
74 |
25 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
194 |
194 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
19 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
306 |
299 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
27 |
12 |
$3K |
| D2394 |
|
17 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$635.70 |