| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
720 |
438 |
$63K |
| D1120 |
Prophylaxis - child |
1,807 |
1,807 |
$52K |
| D1110 |
Prophylaxis - adult |
1,037 |
1,037 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,794 |
2,794 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
1,351 |
1,341 |
$39K |
| D0330 |
Panoramic radiographic image |
735 |
735 |
$34K |
| D7111 |
|
443 |
176 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,208 |
1,208 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
402 |
268 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,234 |
1,168 |
$18K |
| D0272 |
Bitewings - two radiographic images |
941 |
941 |
$16K |
| D0274 |
Bitewings - four radiographic images |
524 |
524 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
84 |
12 |
$10K |
| D3240 |
|
46 |
12 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
516 |
337 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
13 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$1K |
| D2940 |
|
16 |
14 |
$696.96 |