| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
55 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
251 |
250 |
$13K |
| D1110 |
Prophylaxis - adult |
204 |
204 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
30 |
$11K |
| D0274 |
Bitewings - four radiographic images |
181 |
181 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
193 |
190 |
$7K |
| D1206 |
Topical application of fluoride varnish |
223 |
223 |
$7K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
65 |
$4K |
| D1120 |
Prophylaxis - child |
56 |
54 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$524.04 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$0.00 |