| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
542 |
269 |
$51K |
| D7140 |
Extraction, erupted tooth or exposed root |
476 |
96 |
$48K |
| D1110 |
Prophylaxis - adult |
954 |
851 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
526 |
465 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,206 |
1,028 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
858 |
725 |
$25K |
| D0274 |
Bitewings - four radiographic images |
713 |
628 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
196 |
101 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
69 |
$8K |
| D1120 |
Prophylaxis - child |
254 |
231 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
121 |
39 |
$7K |
| D1206 |
Topical application of fluoride varnish |
352 |
332 |
$4K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
17 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
290 |
241 |
$2K |
| D2394 |
|
17 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
56 |
$783.00 |
| D0140 |
Limited oral evaluation - problem focused |
32 |
30 |
$605.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
14 |
$216.00 |
| D0350 |
|
16 |
13 |
$160.03 |