| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
426 |
230 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
255 |
110 |
$22K |
| D9420 |
|
95 |
94 |
$19K |
| D1110 |
Prophylaxis - adult |
301 |
295 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
171 |
166 |
$16K |
| D1120 |
Prophylaxis - child |
394 |
389 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
153 |
47 |
$9K |
| D2394 |
|
28 |
12 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
311 |
304 |
$3K |
| D0350 |
|
95 |
94 |
$1K |
| D1330 |
|
754 |
741 |
$704.98 |
| D1206 |
Topical application of fluoride varnish |
92 |
91 |
$680.77 |
| D0274 |
Bitewings - four radiographic images |
226 |
219 |
$595.79 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$581.61 |
| D1351 |
Sealant - per tooth |
115 |
32 |
$518.53 |
| D0120 |
Periodic oral evaluation - established patient |
353 |
346 |
$103.45 |
| D0272 |
Bitewings - two radiographic images |
131 |
131 |
$32.12 |
| D1208 |
Topical application of fluoride, excluding varnish |
551 |
540 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
13 |
$0.00 |
| D1354 |
|
121 |
16 |
$0.00 |