| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
785 |
766 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
635 |
376 |
$39K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
265 |
60 |
$35K |
| D1110 |
Prophylaxis - adult |
692 |
676 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
897 |
874 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
376 |
241 |
$27K |
| D0274 |
Bitewings - four radiographic images |
692 |
679 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
335 |
329 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
299 |
203 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
381 |
373 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
824 |
771 |
$6K |
| D1120 |
Prophylaxis - child |
89 |
88 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
73 |
$5K |
| D1206 |
Topical application of fluoride varnish |
206 |
206 |
$4K |
| D2332 |
|
44 |
27 |
$3K |
| D2950 |
|
29 |
25 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
821 |
393 |
$3K |
| D2394 |
|
17 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
44 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
31 |
$543.75 |