| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
37 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
40 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
98 |
98 |
$3K |
| D1120 |
Prophylaxis - child |
75 |
75 |
$3K |
| D1110 |
Prophylaxis - adult |
61 |
61 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
54 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
80 |
80 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
75 |
74 |
$2K |
| D0274 |
Bitewings - four radiographic images |
73 |
73 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
16 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
68 |
$865.48 |
| D4355 |
|
12 |
12 |
$827.79 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
12 |
$234.45 |