| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
436 |
276 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,028 |
1,009 |
$10K |
| D1120 |
Prophylaxis - child |
538 |
534 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,097 |
1,064 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
129 |
94 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,991 |
933 |
$5K |
| D1110 |
Prophylaxis - adult |
203 |
200 |
$4K |
| D0274 |
Bitewings - four radiographic images |
576 |
563 |
$3K |
| D1351 |
Sealant - per tooth |
179 |
44 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
106 |
104 |
$980.00 |
| D0330 |
Panoramic radiographic image |
94 |
90 |
$855.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$772.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$200.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$160.00 |
| D1330 |
|
688 |
679 |
$0.00 |