| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
440 |
245 |
$57K |
| D0330 |
Panoramic radiographic image |
1,013 |
1,011 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
887 |
885 |
$36K |
| D1110 |
Prophylaxis - adult |
766 |
763 |
$36K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
221 |
135 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
295 |
168 |
$30K |
| D2740 |
Crown - porcelain/ceramic |
35 |
25 |
$24K |
| D0274 |
Bitewings - four radiographic images |
704 |
704 |
$21K |
| D0350 |
|
227 |
221 |
$20K |
| D4342 |
|
206 |
70 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
519 |
504 |
$18K |
| D1206 |
Topical application of fluoride varnish |
687 |
684 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
492 |
491 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
253 |
251 |
$9K |
| D1120 |
Prophylaxis - child |
232 |
232 |
$7K |
| D1351 |
Sealant - per tooth |
192 |
51 |
$7K |
| D2950 |
|
44 |
38 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
275 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$2K |
| D4910 |
|
12 |
12 |
$783.84 |