| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
435 |
149 |
$33K |
| D1110 |
Prophylaxis - adult |
803 |
744 |
$25K |
| D2394 |
|
172 |
66 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
216 |
78 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
582 |
492 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
739 |
673 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,141 |
1,110 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
277 |
84 |
$17K |
| D1120 |
Prophylaxis - child |
513 |
484 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
591 |
573 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
878 |
405 |
$4K |
| D0274 |
Bitewings - four radiographic images |
222 |
209 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
38 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
788 |
745 |
$4K |
| D2931 |
|
24 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
94 |
94 |
$1K |
| D0350 |
|
19 |
19 |
$233.89 |