| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
672 |
342 |
$40K |
| D1110 |
Prophylaxis - adult |
740 |
735 |
$26K |
| D0330 |
Panoramic radiographic image |
609 |
599 |
$22K |
| D0274 |
Bitewings - four radiographic images |
754 |
745 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
263 |
160 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
697 |
695 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
207 |
87 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
232 |
141 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
584 |
582 |
$11K |
| D1351 |
Sealant - per tooth |
375 |
58 |
$9K |
| D1206 |
Topical application of fluoride varnish |
333 |
332 |
$6K |
| D1120 |
Prophylaxis - child |
186 |
186 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
20 |
20 |
$1K |
| D0272 |
Bitewings - two radiographic images |
55 |
53 |
$848.00 |
| D9110 |
|
15 |
15 |
$420.00 |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
29 |
$212.00 |