| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
271 |
207 |
$16K |
| D1120 |
Prophylaxis - child |
252 |
252 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
375 |
375 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
240 |
192 |
$10K |
| D1110 |
Prophylaxis - adult |
197 |
197 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
305 |
305 |
$8K |
| D0274 |
Bitewings - four radiographic images |
370 |
369 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
870 |
823 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
202 |
202 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
282 |
277 |
$5K |
| D4341 |
|
29 |
14 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
610 |
580 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$765.49 |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
48 |
$607.93 |