| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
513 |
243 |
$50K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
453 |
153 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
884 |
748 |
$30K |
| D0330 |
Panoramic radiographic image |
756 |
650 |
$28K |
| D0274 |
Bitewings - four radiographic images |
675 |
575 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
229 |
116 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,020 |
865 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,161 |
704 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
238 |
223 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
122 |
43 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
33 |
$6K |
| D1110 |
Prophylaxis - adult |
90 |
84 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
119 |
106 |
$2K |
| D4346 |
|
47 |
35 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
27 |
26 |
$668.96 |
| D9110 |
|
12 |
12 |
$530.24 |