| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
526 |
219 |
$30K |
| D2394 |
|
307 |
146 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
334 |
168 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
352 |
132 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
295 |
288 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
428 |
419 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
123 |
52 |
$6K |
| D1110 |
Prophylaxis - adult |
172 |
168 |
$5K |
| D2335 |
|
54 |
19 |
$3K |
| D2332 |
|
43 |
27 |
$3K |
| D0330 |
Panoramic radiographic image |
99 |
94 |
$2K |
| D2331 |
|
18 |
12 |
$1K |
| D0350 |
|
52 |
51 |
$603.19 |
| D1206 |
Topical application of fluoride varnish |
42 |
42 |
$552.00 |
| D1120 |
Prophylaxis - child |
26 |
25 |
$515.20 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$204.96 |