| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,916 |
318 |
$289K |
| D2394 |
|
772 |
170 |
$137K |
| D1110 |
Prophylaxis - adult |
956 |
926 |
$59K |
| D0140 |
Limited oral evaluation - problem focused |
1,175 |
990 |
$48K |
| D0330 |
Panoramic radiographic image |
722 |
702 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
75 |
$27K |
| D0460 |
|
979 |
800 |
$26K |
| D2750 |
|
54 |
15 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
721 |
695 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
278 |
268 |
$17K |
| D9110 |
|
231 |
217 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
96 |
65 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
544 |
520 |
$13K |
| D0274 |
Bitewings - four radiographic images |
286 |
271 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
339 |
323 |
$5K |
| D4355 |
|
13 |
12 |
$1K |
| D0470 |
|
43 |
34 |
$696.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$564.00 |
| D0170 |
|
13 |
12 |
$432.00 |