| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
634 |
398 |
$69K |
| D0330 |
Panoramic radiographic image |
1,304 |
1,279 |
$64K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
493 |
208 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
3,361 |
3,261 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,618 |
1,583 |
$49K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
328 |
191 |
$49K |
| D1110 |
Prophylaxis - adult |
972 |
957 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,322 |
1,294 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,757 |
1,731 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
268 |
43 |
$33K |
| D1120 |
Prophylaxis - child |
1,008 |
990 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,491 |
1,460 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,051 |
2,565 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
722 |
705 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
242 |
155 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
482 |
475 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
49 |
18 |
$4K |
| D4341 |
|
24 |
12 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
25 |
$4K |
| D0272 |
Bitewings - two radiographic images |
135 |
131 |
$2K |
| D0603 |
|
20 |
20 |
$183.00 |