| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
872 |
379 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
864 |
353 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
768 |
743 |
$29K |
| D0330 |
Panoramic radiographic image |
398 |
386 |
$14K |
| D1110 |
Prophylaxis - adult |
475 |
458 |
$13K |
| D0274 |
Bitewings - four radiographic images |
523 |
508 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
113 |
72 |
$9K |
| D1120 |
Prophylaxis - child |
419 |
405 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
368 |
352 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
738 |
710 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
58 |
30 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
156 |
152 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
376 |
360 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
43 |
39 |
$740.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
12 |
$231.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$176.02 |