| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
201 |
106 |
$12K |
| D1110 |
Prophylaxis - adult |
290 |
284 |
$9K |
| D2335 |
|
98 |
45 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
145 |
51 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
372 |
309 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
145 |
140 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
145 |
96 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
215 |
$6K |
| D0274 |
Bitewings - four radiographic images |
148 |
146 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
162 |
160 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
41 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
548 |
452 |
$3K |
| D2394 |
|
34 |
27 |
$3K |
| D2332 |
|
33 |
20 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
436 |
351 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
45 |
$2K |
| D2330 |
|
27 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
94 |
$1K |
| D1120 |
Prophylaxis - child |
48 |
45 |
$840.00 |
| D1320 |
|
18 |
17 |
$832.83 |
| D0240 |
|
49 |
17 |
$396.00 |