| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
14 |
$3K |
| D1110 |
Prophylaxis - adult |
85 |
83 |
$3K |
| D0274 |
Bitewings - four radiographic images |
84 |
83 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
119 |
118 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
66 |
65 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
52 |
50 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
53 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
84 |
$1K |
| D1120 |
Prophylaxis - child |
17 |
17 |
$766.36 |