| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
876 |
436 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
833 |
828 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
737 |
347 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
590 |
590 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
617 |
615 |
$24K |
| D1110 |
Prophylaxis - adult |
303 |
301 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,532 |
1,052 |
$18K |
| D1120 |
Prophylaxis - child |
600 |
598 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
100 |
43 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,056 |
1,053 |
$11K |
| D0274 |
Bitewings - four radiographic images |
439 |
437 |
$8K |
| D0350 |
|
949 |
376 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
12 |
$7K |
| D4341 |
|
126 |
33 |
$7K |
| D2330 |
|
52 |
25 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
215 |
$3K |
| D0272 |
Bitewings - two radiographic images |
225 |
223 |
$3K |
| D1351 |
Sealant - per tooth |
24 |
12 |
$528.00 |