| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
761 |
226 |
$76K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
300 |
159 |
$36K |
| D1110 |
Prophylaxis - adult |
286 |
280 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
120 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
98 |
30 |
$11K |
| D2335 |
|
61 |
32 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
70 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
149 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
180 |
177 |
$6K |
| D2394 |
|
26 |
16 |
$4K |
| D0274 |
Bitewings - four radiographic images |
72 |
71 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
77 |
77 |
$2K |
| D1120 |
Prophylaxis - child |
17 |
17 |
$611.52 |