| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,518 |
1,091 |
$164K |
| D0120 |
Periodic oral evaluation - established patient |
3,884 |
3,569 |
$104K |
| D1110 |
Prophylaxis - adult |
2,465 |
2,305 |
$99K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
881 |
606 |
$64K |
| 99199 |
Unlisted special service, procedure or report |
13,008 |
13,008 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,810 |
1,721 |
$62K |
| D1206 |
Topical application of fluoride varnish |
2,627 |
2,453 |
$44K |
| D0330 |
Panoramic radiographic image |
720 |
691 |
$41K |
| D1120 |
Prophylaxis - child |
1,384 |
1,294 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
289 |
248 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
684 |
655 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
274 |
148 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
483 |
455 |
$17K |
| D0272 |
Bitewings - two radiographic images |
450 |
412 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
515 |
486 |
$8K |
| D9110 |
|
59 |
58 |
$3K |
| D2331 |
|
19 |
13 |
$2K |
| D4355 |
|
12 |
12 |
$797.21 |
| D0170 |
|
13 |
12 |
$370.80 |