| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
17 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$943.36 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$709.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$663.48 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$519.69 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$469.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
36 |
$383.68 |