| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
997 |
494 |
$71K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
635 |
166 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,076 |
970 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
345 |
210 |
$28K |
| D1110 |
Prophylaxis - adult |
724 |
668 |
$27K |
| D0330 |
Panoramic radiographic image |
757 |
692 |
$22K |
| D0274 |
Bitewings - four radiographic images |
876 |
811 |
$20K |
| D1206 |
Topical application of fluoride varnish |
908 |
845 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
371 |
201 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
601 |
560 |
$13K |
| D1120 |
Prophylaxis - child |
317 |
281 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
95 |
12 |
$6K |
| D2331 |
|
33 |
16 |
$2K |
| D1351 |
Sealant - per tooth |
68 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
40 |
$872.44 |