| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2332 |
|
781 |
160 |
$98K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
464 |
76 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
97 |
$32K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
210 |
78 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
57 |
$14K |
| D0330 |
Panoramic radiographic image |
212 |
204 |
$9K |
| D1110 |
Prophylaxis - adult |
207 |
201 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
188 |
169 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
236 |
233 |
$4K |
| D0274 |
Bitewings - four radiographic images |
165 |
162 |
$4K |
| D1120 |
Prophylaxis - child |
157 |
154 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
151 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
147 |
146 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
95 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
54 |
$946.68 |
| D0272 |
Bitewings - two radiographic images |
33 |
32 |
$509.26 |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$385.85 |