| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
677 |
417 |
$82K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
338 |
231 |
$49K |
| D1120 |
Prophylaxis - child |
823 |
823 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
612 |
611 |
$17K |
| D1206 |
Topical application of fluoride varnish |
619 |
619 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
289 |
289 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
998 |
303 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
114 |
112 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
87 |
62 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
457 |
452 |
$7K |
| D1351 |
Sealant - per tooth |
135 |
36 |
$4K |
| D1110 |
Prophylaxis - adult |
67 |
67 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
102 |
102 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
42 |
$2K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$300.00 |