| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4346 |
|
109 |
108 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
169 |
80 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
280 |
280 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
153 |
153 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
296 |
296 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
45 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
13 |
$3K |
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$2K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
49 |
$1K |
| D1110 |
Prophylaxis - adult |
32 |
32 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
43 |
$470.05 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$269.28 |