| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,014 |
955 |
$124K |
| D1110 |
Prophylaxis - adult |
1,348 |
1,342 |
$116K |
| D0120 |
Periodic oral evaluation - established patient |
1,835 |
1,823 |
$113K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,150 |
945 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,281 |
1,274 |
$80K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19,359 |
3,549 |
$75K |
| D1120 |
Prophylaxis - child |
1,522 |
1,520 |
$58K |
| D0274 |
Bitewings - four radiographic images |
2,666 |
2,659 |
$54K |
| D0350 |
|
4,527 |
1,197 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,021 |
2,015 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
779 |
768 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
157 |
84 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
45 |
$5K |
| D0330 |
Panoramic radiographic image |
176 |
176 |
$5K |
| D2330 |
|
28 |
14 |
$2K |
| D9430 |
|
12 |
12 |
$330.00 |
| D1310 |
|
21 |
21 |
$0.00 |
| D1330 |
|
27 |
27 |
$0.00 |