| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
85 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
81 |
56 |
$10K |
| D1120 |
Prophylaxis - child |
235 |
235 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
865 |
417 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
357 |
357 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
316 |
311 |
$7K |
| D1110 |
Prophylaxis - adult |
139 |
139 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
255 |
255 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
488 |
481 |
$4K |
| D1351 |
Sealant - per tooth |
109 |
25 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
25 |
$3K |
| D0274 |
Bitewings - four radiographic images |
108 |
108 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
53 |
$1K |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$866.45 |