| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,138 |
1,173 |
$184K |
| D1110 |
Prophylaxis - adult |
2,660 |
2,650 |
$101K |
| D0210 |
Intraoral - complete series of radiographic images |
2,241 |
2,212 |
$100K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,735 |
560 |
$74K |
| D0140 |
Limited oral evaluation - problem focused |
2,544 |
2,490 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,409 |
2,395 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,863 |
2,853 |
$61K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
642 |
357 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
638 |
376 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
3,809 |
3,710 |
$40K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
382 |
266 |
$40K |
| D2740 |
Crown - porcelain/ceramic |
68 |
40 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,204 |
1,197 |
$29K |
| D1120 |
Prophylaxis - child |
685 |
684 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,282 |
1,976 |
$22K |
| D1206 |
Topical application of fluoride varnish |
843 |
841 |
$17K |
| D2950 |
|
81 |
61 |
$12K |
| D2332 |
|
61 |
39 |
$5K |
| D0330 |
Panoramic radiographic image |
87 |
87 |
$2K |
| D4355 |
|
61 |
61 |
$2K |
| D2330 |
|
20 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
55 |
55 |
$1K |
| D0272 |
Bitewings - two radiographic images |
26 |
25 |
$534.01 |