| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2394 |
|
818 |
557 |
$108K |
| D1110 |
Prophylaxis - adult |
1,318 |
1,318 |
$72K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
614 |
421 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
624 |
407 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,453 |
1,451 |
$40K |
| D0330 |
Panoramic radiographic image |
817 |
817 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
854 |
854 |
$24K |
| D2335 |
|
162 |
86 |
$22K |
| D0274 |
Bitewings - four radiographic images |
554 |
554 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
132 |
82 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
44 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
330 |
323 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
100 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$186.90 |