| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
704 |
317 |
$97K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
716 |
309 |
$77K |
| D7140 |
Extraction, erupted tooth or exposed root |
336 |
159 |
$33K |
| D1110 |
Prophylaxis - adult |
816 |
815 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,185 |
1,184 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
418 |
418 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
691 |
688 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
989 |
977 |
$12K |
| D1120 |
Prophylaxis - child |
390 |
390 |
$12K |
| D0274 |
Bitewings - four radiographic images |
412 |
412 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
357 |
356 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
149 |
148 |
$10K |
| D1206 |
Topical application of fluoride varnish |
366 |
366 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
26 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
278 |
278 |
$3K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$2K |
| D0272 |
Bitewings - two radiographic images |
97 |
97 |
$2K |
| D2330 |
|
18 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
27 |
$909.30 |