| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
33 |
$6K |
| D1120 |
Prophylaxis - child |
117 |
117 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
30 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
128 |
128 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
116 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$3K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
41 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
76 |
$1K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$913.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
30 |
$351.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$300.00 |