| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
326 |
105 |
$15K |
| D1110 |
Prophylaxis - adult |
369 |
248 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
302 |
69 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
444 |
267 |
$8K |
| D0274 |
Bitewings - four radiographic images |
284 |
221 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
369 |
284 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
192 |
43 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
83 |
28 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
27 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
215 |
141 |
$3K |
| D0330 |
Panoramic radiographic image |
181 |
93 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
303 |
191 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
67 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
16 |
$590.85 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
13 |
$176.97 |