| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
37 |
$7K |
| D1120 |
Prophylaxis - child |
120 |
120 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
100 |
100 |
$3K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
63 |
$2K |
| D1206 |
Topical application of fluoride varnish |
73 |
73 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
64 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$981.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$624.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$515.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$117.00 |