| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,746 |
960 |
$190K |
| D1110 |
Prophylaxis - adult |
2,369 |
2,345 |
$93K |
| D0274 |
Bitewings - four radiographic images |
2,569 |
2,527 |
$84K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,291 |
475 |
$83K |
| D0330 |
Panoramic radiographic image |
1,416 |
1,380 |
$82K |
| D4355 |
|
1,191 |
1,169 |
$82K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,016 |
2,856 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,616 |
1,578 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
2,519 |
2,509 |
$64K |
| D0220 |
Intraoral - periapical first radiographic image |
4,033 |
3,793 |
$61K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
453 |
231 |
$49K |
| D0140 |
Limited oral evaluation - problem focused |
1,370 |
1,314 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
548 |
349 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,921 |
1,904 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
222 |
152 |
$29K |
| D2335 |
|
66 |
50 |
$9K |
| D2332 |
|
59 |
37 |
$6K |
| D4341 |
|
32 |
14 |
$3K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$483.75 |