| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,128 |
649 |
$110K |
| D1110 |
Prophylaxis - adult |
1,025 |
1,025 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
569 |
390 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
457 |
239 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
260 |
176 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,307 |
1,307 |
$30K |
| D1120 |
Prophylaxis - child |
818 |
818 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,142 |
2,101 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,437 |
1,437 |
$27K |
| D0330 |
Panoramic radiographic image |
547 |
547 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,602 |
1,602 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,763 |
1,811 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
584 |
584 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
389 |
381 |
$14K |
| D0274 |
Bitewings - four radiographic images |
300 |
300 |
$8K |
| D1351 |
Sealant - per tooth |
102 |
30 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
15 |
$3K |