| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
503 |
268 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
189 |
114 |
$12K |
| D0330 |
Panoramic radiographic image |
346 |
342 |
$10K |
| D1110 |
Prophylaxis - adult |
385 |
384 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
157 |
157 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
619 |
615 |
$6K |
| D1206 |
Topical application of fluoride varnish |
355 |
352 |
$2K |
| D2332 |
|
44 |
26 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
62 |
29 |
$2K |
| D0274 |
Bitewings - four radiographic images |
97 |
97 |
$610.62 |
| D0220 |
Intraoral - periapical first radiographic image |
160 |
154 |
$264.56 |
| D1330 |
|
53 |
53 |
$189.18 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$150.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
133 |
124 |
$138.76 |
| D7311 |
|
13 |
13 |
$0.00 |