| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
218 |
113 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
141 |
25 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
31 |
$10K |
| D1110 |
Prophylaxis - adult |
168 |
149 |
$7K |
| D1206 |
Topical application of fluoride varnish |
324 |
297 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
269 |
241 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
149 |
$3K |
| D0274 |
Bitewings - four radiographic images |
75 |
66 |
$2K |
| D1120 |
Prophylaxis - child |
49 |
46 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
25 |
$940.89 |
| D0230 |
Intraoral - periapical each additional radiographic image |
120 |
65 |
$903.63 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$369.28 |