| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
213 |
137 |
$39K |
| D1110 |
Prophylaxis - adult |
252 |
251 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
243 |
241 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
245 |
236 |
$13K |
| D1120 |
Prophylaxis - child |
211 |
210 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
307 |
301 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
188 |
186 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
99 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
395 |
382 |
$8K |
| D0274 |
Bitewings - four radiographic images |
102 |
100 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
235 |
181 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
16 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
60 |
60 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$773.60 |
| D0270 |
|
13 |
13 |
$275.20 |