| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
482 |
201 |
$48K |
| D1110 |
Prophylaxis - adult |
938 |
888 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
737 |
681 |
$30K |
| D0274 |
Bitewings - four radiographic images |
923 |
847 |
$26K |
| D0330 |
Panoramic radiographic image |
470 |
428 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
813 |
769 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,339 |
1,201 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,189 |
986 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
75 |
25 |
$8K |
| D1206 |
Topical application of fluoride varnish |
350 |
333 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
135 |
122 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
41 |
38 |
$986.10 |
| D0801 |
|
19 |
15 |
$0.00 |