| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
636 |
407 |
$37K |
| D1110 |
Prophylaxis - adult |
478 |
472 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
896 |
866 |
$23K |
| D1120 |
Prophylaxis - child |
342 |
339 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
683 |
678 |
$16K |
| D1206 |
Topical application of fluoride varnish |
899 |
888 |
$13K |
| D0330 |
Panoramic radiographic image |
326 |
315 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
228 |
223 |
$12K |
| D0274 |
Bitewings - four radiographic images |
330 |
319 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
223 |
157 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
261 |
247 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
63 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
112 |
74 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
828 |
801 |
$6K |
| D2332 |
|
45 |
31 |
$3K |
| D0272 |
Bitewings - two radiographic images |
75 |
75 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
25 |
$276.59 |
| D1999 |
|
332 |
271 |
$0.00 |