| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
610 |
232 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,128 |
716 |
$34K |
| D1110 |
Prophylaxis - adult |
857 |
645 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
476 |
296 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
564 |
507 |
$16K |
| D1120 |
Prophylaxis - child |
336 |
316 |
$12K |
| D1206 |
Topical application of fluoride varnish |
300 |
291 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
41 |
$8K |
| D0330 |
Panoramic radiographic image |
234 |
154 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
238 |
228 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
58 |
14 |
$3K |
| D0272 |
Bitewings - two radiographic images |
135 |
122 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
219 |
155 |
$2K |
| D0274 |
Bitewings - four radiographic images |
109 |
39 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
35 |
24 |
$491.20 |