| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
35 |
$8K |
| D1110 |
Prophylaxis - adult |
154 |
149 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
30 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
149 |
$5K |
| D1120 |
Prophylaxis - child |
110 |
110 |
$4K |
| D1351 |
Sealant - per tooth |
131 |
29 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
148 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
113 |
113 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
57 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
129 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$2K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
93 |
$900.75 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$361.07 |