| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
385 |
219 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
923 |
923 |
$24K |
| D1110 |
Prophylaxis - adult |
471 |
471 |
$23K |
| D1120 |
Prophylaxis - child |
597 |
597 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
216 |
118 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
799 |
781 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
176 |
174 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
279 |
276 |
$10K |
| D1206 |
Topical application of fluoride varnish |
462 |
462 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
151 |
44 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
198 |
195 |
$7K |
| D0274 |
Bitewings - four radiographic images |
202 |
202 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
651 |
575 |
$5K |
| D1351 |
Sealant - per tooth |
176 |
52 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
57 |
28 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
172 |
172 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
92 |
92 |
$2K |
| D4355 |
|
16 |
16 |
$661.00 |