| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
678 |
312 |
$67K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
542 |
249 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
549 |
503 |
$22K |
| D0330 |
Panoramic radiographic image |
347 |
329 |
$16K |
| D0274 |
Bitewings - four radiographic images |
400 |
366 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
819 |
389 |
$10K |
| D2394 |
|
55 |
26 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
581 |
535 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
42 |
$5K |
| D4355 |
|
78 |
75 |
$5K |
| D1110 |
Prophylaxis - adult |
128 |
125 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
135 |
127 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
28 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
81 |
79 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$615.04 |
| D1120 |
Prophylaxis - child |
14 |
12 |
$341.52 |