| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
450 |
202 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
420 |
212 |
$49K |
| D1110 |
Prophylaxis - adult |
501 |
500 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
601 |
600 |
$16K |
| D1120 |
Prophylaxis - child |
355 |
355 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
300 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
648 |
639 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
234 |
234 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
585 |
480 |
$5K |
| D1206 |
Topical application of fluoride varnish |
232 |
232 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$3K |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$3K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$951.00 |