| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
354 |
197 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
675 |
675 |
$18K |
| D1110 |
Prophylaxis - adult |
351 |
350 |
$18K |
| D1206 |
Topical application of fluoride varnish |
740 |
740 |
$17K |
| D1120 |
Prophylaxis - child |
422 |
422 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
357 |
$15K |
| D0274 |
Bitewings - four radiographic images |
398 |
398 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
87 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
12 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
94 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
110 |
108 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
17 |
$352.04 |