| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,109 |
744 |
$140K |
| D1110 |
Prophylaxis - adult |
1,033 |
1,032 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
1,161 |
1,135 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
286 |
247 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,074 |
1,070 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
1,958 |
1,902 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
723 |
721 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
303 |
217 |
$30K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
170 |
85 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
855 |
854 |
$24K |
| D1120 |
Prophylaxis - child |
484 |
484 |
$20K |
| D1351 |
Sealant - per tooth |
618 |
66 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,613 |
1,417 |
$16K |
| D0330 |
Panoramic radiographic image |
144 |
144 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
378 |
378 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
93 |
74 |
$7K |
| D1206 |
Topical application of fluoride varnish |
160 |
160 |
$4K |
| D0272 |
Bitewings - two radiographic images |
94 |
94 |
$2K |
| D0270 |
|
89 |
89 |
$989.42 |