| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,482 |
2,053 |
$253K |
| D1110 |
Prophylaxis - adult |
4,286 |
4,284 |
$195K |
| D0120 |
Periodic oral evaluation - established patient |
4,262 |
4,261 |
$98K |
| D0330 |
Panoramic radiographic image |
1,980 |
1,980 |
$69K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,186 |
783 |
$55K |
| D1120 |
Prophylaxis - child |
1,350 |
1,350 |
$46K |
| D4341 |
|
721 |
252 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,743 |
1,743 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,480 |
1,480 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
3,016 |
2,970 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
456 |
403 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,752 |
1,752 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,360 |
2,356 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
134 |
103 |
$11K |
| D2331 |
|
80 |
63 |
$6K |
| D9110 |
|
166 |
166 |
$3K |
| D1351 |
Sealant - per tooth |
38 |
13 |
$2K |
| D2330 |
|
35 |
25 |
$1K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$520.80 |
| D9991 |
|
15 |
14 |
$135.00 |
| D1330 |
|
19 |
19 |
$0.00 |