| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,507 |
922 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,250 |
1,260 |
$54K |
| D1110 |
Prophylaxis - adult |
1,699 |
1,689 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
753 |
744 |
$41K |
| D0330 |
Panoramic radiographic image |
1,295 |
1,287 |
$32K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
666 |
328 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,004 |
1,990 |
$23K |
| D0274 |
Bitewings - four radiographic images |
2,036 |
2,025 |
$18K |
| D4341 |
|
1,030 |
291 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
919 |
517 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
772 |
738 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
967 |
962 |
$6K |
| D1206 |
Topical application of fluoride varnish |
2,108 |
2,091 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,338 |
2,132 |
$4K |
| D2331 |
|
53 |
38 |
$1K |
| D2332 |
|
26 |
16 |
$1K |
| D1120 |
Prophylaxis - child |
19 |
19 |
$952.39 |
| D1330 |
|
2,196 |
2,180 |
$914.91 |
| D0220 |
Intraoral - periapical first radiographic image |
2,418 |
2,378 |
$665.29 |