| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
506 |
258 |
$25K |
| D1110 |
Prophylaxis - adult |
454 |
445 |
$15K |
| D0274 |
Bitewings - four radiographic images |
592 |
576 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
718 |
705 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
200 |
122 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
254 |
240 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
403 |
392 |
$10K |
| D1120 |
Prophylaxis - child |
216 |
215 |
$4K |
| D1206 |
Topical application of fluoride varnish |
230 |
230 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
545 |
300 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
421 |
408 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
32 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
77 |
$976.50 |
| D0330 |
Panoramic radiographic image |
20 |
20 |
$740.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$564.50 |