| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
930 |
522 |
$48K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
516 |
139 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
475 |
287 |
$19K |
| D0330 |
Panoramic radiographic image |
443 |
429 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
288 |
215 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
872 |
863 |
$18K |
| D1110 |
Prophylaxis - adult |
546 |
542 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,036 |
1,026 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
598 |
575 |
$13K |
| D0274 |
Bitewings - four radiographic images |
546 |
531 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
240 |
112 |
$13K |
| D1120 |
Prophylaxis - child |
546 |
540 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
320 |
312 |
$8K |
| D0272 |
Bitewings - two radiographic images |
222 |
221 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
527 |
499 |
$4K |
| D2331 |
|
64 |
42 |
$4K |
| D2394 |
|
43 |
33 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
481 |
289 |
$3K |
| D2330 |
|
25 |
16 |
$1K |
| D1351 |
Sealant - per tooth |
41 |
12 |
$860.01 |
| D1330 |
|
51 |
51 |
$754.32 |
| D1310 |
|
47 |
47 |
$0.00 |