| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
715 |
432 |
$79K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
476 |
73 |
$59K |
| D0330 |
Panoramic radiographic image |
866 |
866 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
230 |
159 |
$38K |
| D4341 |
|
190 |
75 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
896 |
896 |
$26K |
| D1320 |
|
732 |
732 |
$25K |
| D0274 |
Bitewings - four radiographic images |
825 |
825 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,470 |
1,419 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,681 |
1,109 |
$21K |
| D1110 |
Prophylaxis - adult |
454 |
454 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,084 |
1,012 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
238 |
77 |
$17K |
| D5140 |
|
17 |
17 |
$14K |
| D5130 |
|
17 |
17 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
168 |
122 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
288 |
286 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
314 |
314 |
$6K |
| D1120 |
Prophylaxis - child |
189 |
189 |
$6K |
| D4910 |
|
75 |
75 |
$5K |
| D0603 |
|
317 |
317 |
$3K |
| D0350 |
|
46 |
46 |
$1K |
| D5411 |
|
29 |
24 |
$1K |
| D5410 |
|
13 |
12 |
$434.83 |