| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
585 |
239 |
$55K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
335 |
189 |
$47K |
| D0330 |
Panoramic radiographic image |
1,014 |
1,014 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
346 |
166 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
878 |
878 |
$35K |
| D1110 |
Prophylaxis - adult |
568 |
568 |
$28K |
| D0274 |
Bitewings - four radiographic images |
724 |
724 |
$19K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
32 |
25 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,371 |
1,362 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
409 |
405 |
$15K |
| D2950 |
|
72 |
53 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
985 |
983 |
$10K |
| D2394 |
|
37 |
25 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
41 |
$5K |
| D1206 |
Topical application of fluoride varnish |
304 |
304 |
$5K |
| D2332 |
|
35 |
16 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
50 |
50 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$201.06 |