| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
441 |
221 |
$40K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
55 |
44 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
273 |
148 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
289 |
69 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
358 |
346 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
628 |
602 |
$22K |
| D1110 |
Prophylaxis - adult |
591 |
563 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
284 |
131 |
$21K |
| D2394 |
|
117 |
65 |
$19K |
| D0274 |
Bitewings - four radiographic images |
316 |
300 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
375 |
353 |
$7K |
| D1120 |
Prophylaxis - child |
157 |
151 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
145 |
139 |
$3K |
| D2332 |
|
30 |
15 |
$2K |
| D2331 |
|
19 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
111 |
$943.25 |
| D1206 |
Topical application of fluoride varnish |
79 |
65 |
$918.00 |
| D0350 |
|
61 |
36 |
$443.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
25 |
$268.00 |