| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
67 |
$13K |
| D0274 |
Bitewings - four radiographic images |
419 |
419 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
51 |
$12K |
| D1110 |
Prophylaxis - adult |
168 |
168 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
570 |
567 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
185 |
185 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
175 |
175 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
321 |
321 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
25 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
25 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
136 |
135 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$584.70 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$506.25 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$140.00 |