| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
671 |
333 |
$67K |
| D4355 |
|
565 |
553 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
266 |
170 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
810 |
803 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,523 |
714 |
$17K |
| D0274 |
Bitewings - four radiographic images |
566 |
558 |
$17K |
| D0330 |
Panoramic radiographic image |
272 |
266 |
$15K |
| D1110 |
Prophylaxis - adult |
370 |
367 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
842 |
828 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
107 |
41 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
266 |
255 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
205 |
199 |
$7K |
| D2332 |
|
72 |
42 |
$7K |
| D1206 |
Topical application of fluoride varnish |
363 |
356 |
$6K |
| D2335 |
|
45 |
24 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
42 |
$4K |
| D2394 |
|
25 |
12 |
$4K |
| D7311 |
|
42 |
26 |
$4K |
| D4341 |
|
29 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
82 |
$1K |
| D1120 |
Prophylaxis - child |
35 |
32 |
$801.97 |