| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,063 |
370 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,176 |
381 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,206 |
402 |
$57K |
| D7140 |
Extraction, erupted tooth or exposed root |
412 |
93 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
633 |
620 |
$16K |
| D2394 |
|
199 |
100 |
$13K |
| D2332 |
|
189 |
53 |
$13K |
| D1110 |
Prophylaxis - adult |
338 |
329 |
$11K |
| D0274 |
Bitewings - four radiographic images |
541 |
524 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,608 |
796 |
$8K |
| D0330 |
Panoramic radiographic image |
211 |
202 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
384 |
264 |
$8K |
| D2335 |
|
64 |
27 |
$5K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
12 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,059 |
958 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
255 |
244 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
144 |
137 |
$3K |
| D4341 |
|
29 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
115 |
114 |
$2K |
| D2331 |
|
22 |
12 |
$1K |
| D2330 |
|
27 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$800.00 |
| D0350 |
|
26 |
26 |
$320.06 |
| D0270 |
|
16 |
16 |
$80.00 |