| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
310 |
142 |
$16K |
| D0330 |
Panoramic radiographic image |
328 |
317 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
515 |
482 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
427 |
420 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
186 |
178 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
97 |
$8K |
| D2335 |
|
59 |
28 |
$6K |
| D0250 |
|
434 |
424 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
70 |
45 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
56 |
24 |
$3K |
| D1110 |
Prophylaxis - adult |
77 |
74 |
$2K |
| D2332 |
|
24 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
428 |
107 |
$2K |
| D2330 |
|
39 |
24 |
$1K |
| D0274 |
Bitewings - four radiographic images |
99 |
98 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
214 |
200 |
$874.50 |