| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2394 |
|
144 |
83 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
351 |
266 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
262 |
196 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
136 |
101 |
$7K |
| D1110 |
Prophylaxis - adult |
191 |
163 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
14 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
31 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
365 |
253 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
41 |
41 |
$1K |
| D1120 |
Prophylaxis - child |
20 |
17 |
$455.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
13 |
$285.92 |
| D0272 |
Bitewings - two radiographic images |
17 |
12 |
$232.20 |
| D1206 |
Topical application of fluoride varnish |
20 |
13 |
$201.36 |