| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
614 |
389 |
$41K |
| D1120 |
Prophylaxis - child |
1,010 |
999 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,029 |
1,015 |
$28K |
| D4341 |
|
182 |
83 |
$28K |
| D1110 |
Prophylaxis - adult |
535 |
529 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
927 |
916 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
947 |
936 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,088 |
1,079 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
328 |
245 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,648 |
1,625 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,792 |
1,460 |
$10K |
| D1351 |
Sealant - per tooth |
160 |
63 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
97 |
83 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
131 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
194 |
189 |
$4K |
| D0272 |
Bitewings - two radiographic images |
288 |
287 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
75 |
$789.02 |
| D1999 |
|
814 |
738 |
$0.00 |