| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
371 |
260 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
289 |
203 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
226 |
225 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
399 |
398 |
$13K |
| D1110 |
Prophylaxis - adult |
207 |
207 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
204 |
204 |
$6K |
| D1120 |
Prophylaxis - child |
88 |
88 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
57 |
$5K |
| D1206 |
Topical application of fluoride varnish |
164 |
164 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
28 |
$3K |
| D2394 |
|
26 |
24 |
$3K |
| D0274 |
Bitewings - four radiographic images |
80 |
80 |
$3K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$270.00 |