| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
736 |
408 |
$80K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
526 |
176 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
691 |
347 |
$57K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
393 |
246 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,163 |
1,112 |
$49K |
| D0330 |
Panoramic radiographic image |
686 |
667 |
$33K |
| D0274 |
Bitewings - four radiographic images |
831 |
807 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,790 |
991 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,339 |
1,245 |
$20K |
| D1110 |
Prophylaxis - adult |
521 |
508 |
$19K |
| D1206 |
Topical application of fluoride varnish |
908 |
875 |
$14K |
| D1120 |
Prophylaxis - child |
449 |
442 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
425 |
423 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
291 |
280 |
$10K |
| D2394 |
|
65 |
39 |
$10K |
| D2335 |
|
46 |
25 |
$6K |
| D0272 |
Bitewings - two radiographic images |
207 |
203 |
$4K |
| D0240 |
|
26 |
13 |
$434.46 |