| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
735 |
444 |
$40K |
| D1110 |
Prophylaxis - adult |
955 |
938 |
$33K |
| D0330 |
Panoramic radiographic image |
599 |
584 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
388 |
217 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,103 |
1,083 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
275 |
120 |
$16K |
| D0274 |
Bitewings - four radiographic images |
975 |
957 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
215 |
141 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
846 |
825 |
$13K |
| D1120 |
Prophylaxis - child |
586 |
569 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
388 |
376 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
483 |
459 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
64 |
16 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
685 |
649 |
$3K |
| D0272 |
Bitewings - two radiographic images |
241 |
238 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
779 |
212 |
$2K |
| D0180 |
|
15 |
15 |
$415.05 |