| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
229 |
96 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
85 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
407 |
394 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
295 |
295 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
554 |
519 |
$5K |
| D1120 |
Prophylaxis - child |
114 |
114 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
145 |
145 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
462 |
244 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
73 |
$3K |
| D1110 |
Prophylaxis - adult |
98 |
96 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
27 |
$2K |
| D4355 |
|
28 |
28 |
$2K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$268.70 |