| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,085 |
598 |
$149K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
700 |
389 |
$75K |
| D7140 |
Extraction, erupted tooth or exposed root |
611 |
165 |
$59K |
| D1110 |
Prophylaxis - adult |
1,361 |
1,359 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
226 |
129 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
910 |
906 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,368 |
1,366 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
327 |
323 |
$24K |
| D2752 |
|
58 |
51 |
$23K |
| D0274 |
Bitewings - four radiographic images |
348 |
348 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
222 |
218 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
597 |
572 |
$7K |
| D2950 |
|
60 |
55 |
$7K |
| D1206 |
Topical application of fluoride varnish |
262 |
262 |
$4K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$2K |
| D2330 |
|
18 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
42 |
$1K |
| D4910 |
|
14 |
14 |
$874.72 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$511.02 |