| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
614 |
254 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,835 |
1,804 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,029 |
548 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
953 |
443 |
$21K |
| D1110 |
Prophylaxis - adult |
867 |
855 |
$18K |
| D0330 |
Panoramic radiographic image |
753 |
743 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
660 |
643 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
245 |
241 |
$4K |
| D1330 |
|
1,123 |
1,112 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
747 |
741 |
$1K |
| D2330 |
|
28 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
537 |
523 |
$741.73 |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
13 |
$532.08 |
| D0274 |
Bitewings - four radiographic images |
102 |
102 |
$323.98 |
| D0140 |
Limited oral evaluation - problem focused |
32 |
31 |
$250.45 |
| D0230 |
Intraoral - periapical each additional radiographic image |
158 |
134 |
$135.77 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$77.24 |
| D0350 |
|
16 |
16 |
$0.00 |