| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
219 |
83 |
$4K |
| D1120 |
Prophylaxis - child |
269 |
242 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
512 |
464 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,679 |
1,529 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
590 |
537 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
530 |
469 |
$1K |
| D0274 |
Bitewings - four radiographic images |
309 |
275 |
$1K |
| D1110 |
Prophylaxis - adult |
170 |
154 |
$932.12 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
94 |
$850.20 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
25 |
$792.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
163 |
150 |
$273.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
12 |
$248.01 |
| D0272 |
Bitewings - two radiographic images |
27 |
25 |
$237.47 |
| D0350 |
|
13 |
12 |
$0.00 |
| D1999 |
|
26 |
22 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
30 |
13 |
$0.00 |
| D2950 |
|
29 |
15 |
$0.00 |