| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1352 |
|
157 |
55 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
54 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
43 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
273 |
273 |
$6K |
| D1120 |
Prophylaxis - child |
127 |
127 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
144 |
144 |
$3K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D4355 |
|
15 |
15 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
54 |
$732.29 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
17 |
$187.35 |