| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
984 |
235 |
$88K |
| D7140 |
Extraction, erupted tooth or exposed root |
683 |
158 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,545 |
1,545 |
$44K |
| D1110 |
Prophylaxis - adult |
942 |
942 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
555 |
555 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
280 |
140 |
$32K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
200 |
99 |
$29K |
| D5110 |
|
41 |
41 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,017 |
1,017 |
$24K |
| D0274 |
Bitewings - four radiographic images |
681 |
681 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,475 |
1,453 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
397 |
397 |
$16K |
| D1120 |
Prophylaxis - child |
580 |
580 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
487 |
481 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
656 |
656 |
$9K |
| D5120 |
|
12 |
12 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
961 |
919 |
$8K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$530.04 |