| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,145 |
623 |
$152K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,133 |
398 |
$110K |
| D1110 |
Prophylaxis - adult |
1,658 |
1,573 |
$79K |
| D0140 |
Limited oral evaluation - problem focused |
1,417 |
1,329 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,189 |
1,165 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,534 |
1,445 |
$38K |
| D0330 |
Panoramic radiographic image |
642 |
637 |
$33K |
| D0274 |
Bitewings - four radiographic images |
605 |
593 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,270 |
1,210 |
$16K |
| D1120 |
Prophylaxis - child |
300 |
277 |
$11K |
| D1206 |
Topical application of fluoride varnish |
446 |
419 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
31 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
36 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
206 |
169 |
$5K |
| D0272 |
Bitewings - two radiographic images |
132 |
130 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
30 |
$2K |
| D4910 |
|
12 |
12 |
$820.13 |