| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
970 |
445 |
$75K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
301 |
195 |
$27K |
| D1110 |
Prophylaxis - adult |
547 |
547 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
412 |
229 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
629 |
629 |
$23K |
| D0330 |
Panoramic radiographic image |
300 |
300 |
$14K |
| D0274 |
Bitewings - four radiographic images |
484 |
483 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
110 |
69 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
364 |
354 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
801 |
761 |
$9K |
| D4341 |
|
66 |
28 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
592 |
570 |
$6K |
| D1120 |
Prophylaxis - child |
144 |
144 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
170 |
170 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$822.00 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$335.56 |