| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
359 |
124 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
47 |
$11K |
| D1110 |
Prophylaxis - adult |
151 |
150 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$9K |
| D0274 |
Bitewings - four radiographic images |
216 |
216 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
184 |
183 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
31 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
41 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
200 |
200 |
$7K |
| D2331 |
|
38 |
14 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
130 |
130 |
$4K |
| D1120 |
Prophylaxis - child |
79 |
79 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
95 |
$963.85 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$510.90 |