| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
649 |
130 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
610 |
466 |
$17K |
| D1120 |
Prophylaxis - child |
1,082 |
616 |
$16K |
| D1206 |
Topical application of fluoride varnish |
982 |
555 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
704 |
378 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
95 |
25 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
29 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
81 |
26 |
$5K |
| D0330 |
Panoramic radiographic image |
237 |
135 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
502 |
387 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
94 |
39 |
$709.38 |
| D0274 |
Bitewings - four radiographic images |
40 |
26 |
$412.40 |
| D0120 |
Periodic oral evaluation - established patient |
20 |
12 |
$329.14 |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
13 |
$0.00 |