| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
476 |
125 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
451 |
97 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
75 |
43 |
$11K |
| D1120 |
Prophylaxis - child |
258 |
258 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
342 |
341 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
310 |
310 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
95 |
43 |
$7K |
| D1110 |
Prophylaxis - adult |
117 |
116 |
$6K |
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
67 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
60 |
$990.29 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$275.00 |