| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
853 |
573 |
$87K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
641 |
458 |
$79K |
| D1110 |
Prophylaxis - adult |
1,173 |
1,111 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
650 |
605 |
$43K |
| D2394 |
|
303 |
216 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
810 |
755 |
$33K |
| D0330 |
Panoramic radiographic image |
391 |
374 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
629 |
571 |
$20K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
106 |
39 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
409 |
395 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
635 |
585 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
713 |
231 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
66 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
15 |
14 |
$6K |
| D2335 |
|
44 |
27 |
$5K |
| D2331 |
|
44 |
31 |
$3K |
| D1206 |
Topical application of fluoride varnish |
151 |
147 |
$2K |
| D0160 |
|
35 |
32 |
$2K |
| D4355 |
|
33 |
30 |
$2K |
| D0274 |
Bitewings - four radiographic images |
49 |
49 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
24 |
$414.96 |