| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,211 |
651 |
$109K |
| D1110 |
Prophylaxis - adult |
1,226 |
1,226 |
$61K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
403 |
244 |
$56K |
| D0140 |
Limited oral evaluation - problem focused |
1,471 |
1,457 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,256 |
1,256 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
419 |
293 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
2,445 |
2,409 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
371 |
235 |
$27K |
| D0274 |
Bitewings - four radiographic images |
785 |
785 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,925 |
1,326 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
649 |
649 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
295 |
295 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
160 |
97 |
$14K |
| D1206 |
Topical application of fluoride varnish |
721 |
721 |
$12K |
| D1120 |
Prophylaxis - child |
269 |
269 |
$10K |
| D1351 |
Sealant - per tooth |
181 |
43 |
$5K |
| D0330 |
Panoramic radiographic image |
81 |
81 |
$4K |
| D2332 |
|
27 |
17 |
$3K |
| D2394 |
|
12 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$667.88 |