| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
39 |
$6K |
| D1120 |
Prophylaxis - child |
80 |
80 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
118 |
118 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
109 |
109 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
34 |
$869.05 |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
51 |
$603.72 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$438.34 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$241.80 |