| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,517 |
783 |
$145K |
| D1110 |
Prophylaxis - adult |
2,601 |
2,601 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
2,535 |
2,535 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,440 |
1,440 |
$37K |
| D1206 |
Topical application of fluoride varnish |
2,124 |
2,124 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
826 |
826 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
696 |
695 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
173 |
102 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,309 |
1,287 |
$16K |
| D0330 |
Panoramic radiographic image |
201 |
201 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
66 |
$7K |
| D1120 |
Prophylaxis - child |
230 |
230 |
$7K |
| D0272 |
Bitewings - two radiographic images |
316 |
316 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
87 |
87 |
$5K |
| D2950 |
|
27 |
25 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
12 |
$163.78 |