| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2991 |
|
899 |
105 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,057 |
543 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
523 |
323 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
230 |
162 |
$25K |
| D0330 |
Panoramic radiographic image |
336 |
327 |
$23K |
| D2722 |
|
23 |
15 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
198 |
86 |
$19K |
| D1110 |
Prophylaxis - adult |
333 |
328 |
$18K |
| D0274 |
Bitewings - four radiographic images |
458 |
442 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
387 |
366 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,296 |
572 |
$14K |
| D1206 |
Topical application of fluoride varnish |
428 |
415 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
770 |
729 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
302 |
301 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
213 |
$8K |
| D2331 |
|
43 |
27 |
$5K |
| D1330 |
|
107 |
107 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
29 |
18 |
$3K |
| D4355 |
|
44 |
44 |
$3K |
| D2950 |
|
13 |
12 |
$2K |
| D9110 |
|
14 |
13 |
$618.43 |