| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,081 |
564 |
$62K |
| D1110 |
Prophylaxis - adult |
1,749 |
1,702 |
$56K |
| D7140 |
Extraction, erupted tooth or exposed root |
918 |
279 |
$45K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
357 |
233 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,038 |
1,010 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
383 |
213 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
995 |
977 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
433 |
424 |
$18K |
| D0274 |
Bitewings - four radiographic images |
523 |
514 |
$13K |
| D0330 |
Panoramic radiographic image |
110 |
109 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
361 |
354 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
238 |
$2K |
| D1206 |
Topical application of fluoride varnish |
91 |
90 |
$1K |
| D2331 |
|
18 |
13 |
$983.76 |