| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,181 |
673 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,808 |
907 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,327 |
1,293 |
$41K |
| D1110 |
Prophylaxis - adult |
875 |
851 |
$39K |
| D0330 |
Panoramic radiographic image |
733 |
718 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,018 |
577 |
$14K |
| D4355 |
|
539 |
529 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
329 |
209 |
$9K |
| D5213 |
|
16 |
16 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
761 |
741 |
$7K |
| D2332 |
|
47 |
27 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,932 |
1,872 |
$694.47 |
| D5214 |
|
15 |
15 |
$631.39 |
| D2331 |
|
156 |
99 |
$612.56 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,747 |
1,709 |
$427.29 |
| D0274 |
Bitewings - four radiographic images |
1,649 |
1,607 |
$232.13 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,728 |
1,683 |
$26.95 |
| D1330 |
|
1,769 |
1,729 |
$3.00 |
| D0190 |
|
726 |
707 |
$0.00 |