| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
925 |
264 |
$112K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
271 |
129 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
232 |
128 |
$21K |
| D1120 |
Prophylaxis - child |
396 |
396 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
185 |
101 |
$15K |
| D1206 |
Topical application of fluoride varnish |
446 |
446 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
279 |
276 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
295 |
295 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
386 |
386 |
$9K |
| D2331 |
|
77 |
48 |
$7K |
| D0330 |
Panoramic radiographic image |
111 |
111 |
$7K |
| D1110 |
Prophylaxis - adult |
149 |
149 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
266 |
262 |
$3K |
| D0274 |
Bitewings - four radiographic images |
117 |
117 |
$3K |
| D2332 |
|
16 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
252 |
177 |
$2K |