| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
738 |
293 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
646 |
322 |
$65K |
| D1110 |
Prophylaxis - adult |
1,028 |
1,028 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,258 |
1,258 |
$51K |
| D0330 |
Panoramic radiographic image |
999 |
996 |
$35K |
| D7240 |
Removal of impacted tooth - completely bony |
91 |
30 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,835 |
1,793 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
193 |
119 |
$23K |
| D0274 |
Bitewings - four radiographic images |
956 |
956 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
158 |
85 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,288 |
1,288 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
559 |
550 |
$21K |
| D1120 |
Prophylaxis - child |
578 |
578 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,558 |
977 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
654 |
654 |
$16K |
| D2950 |
|
76 |
50 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
18 |
17 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
14 |
$4K |
| D2931 |
|
20 |
18 |
$3K |
| D2332 |
|
23 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$755.90 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$274.50 |