| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,211 |
668 |
$81K |
| D1110 |
Prophylaxis - adult |
1,505 |
1,493 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,105 |
2,099 |
$56K |
| D1206 |
Topical application of fluoride varnish |
2,749 |
2,734 |
$51K |
| D1120 |
Prophylaxis - child |
1,163 |
1,154 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
598 |
330 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,261 |
1,253 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
748 |
747 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
303 |
199 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
354 |
351 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
348 |
333 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
597 |
569 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
27 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
403 |
161 |
$3K |
| D0601 |
|
337 |
337 |
$3K |
| D1999 |
|
251 |
219 |
$2K |
| D0330 |
Panoramic radiographic image |
107 |
107 |
$2K |
| D0602 |
|
101 |
100 |
$990.00 |
| D0603 |
|
68 |
68 |
$671.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$500.00 |
| D0180 |
|
12 |
12 |
$420.00 |
| D0270 |
|
32 |
27 |
$341.00 |
| D1330 |
|
12 |
12 |
$0.00 |