| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
660 |
378 |
$38K |
| D1110 |
Prophylaxis - adult |
853 |
842 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,216 |
1,210 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
354 |
172 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
322 |
215 |
$20K |
| D1120 |
Prophylaxis - child |
653 |
650 |
$19K |
| D0274 |
Bitewings - four radiographic images |
693 |
685 |
$18K |
| D1206 |
Topical application of fluoride varnish |
782 |
777 |
$14K |
| D0330 |
Panoramic radiographic image |
342 |
336 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
177 |
106 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
317 |
308 |
$8K |
| D9110 |
|
134 |
132 |
$4K |
| D2332 |
|
63 |
45 |
$4K |
| D0601 |
|
319 |
319 |
$3K |
| D1351 |
Sealant - per tooth |
84 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
41 |
$2K |
| D2335 |
|
29 |
14 |
$2K |
| D1330 |
|
324 |
324 |
$2K |
| D2394 |
|
15 |
14 |
$805.00 |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
88 |
$661.74 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$137.00 |