| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
440 |
169 |
$51K |
| D1110 |
Prophylaxis - adult |
700 |
700 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,139 |
1,139 |
$29K |
| D1120 |
Prophylaxis - child |
708 |
708 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,247 |
1,243 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,803 |
631 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
656 |
654 |
$10K |
| D0274 |
Bitewings - four radiographic images |
235 |
235 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
153 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
12 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$450.00 |