| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
139 |
55 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
104 |
29 |
$8K |
| D1120 |
Prophylaxis - child |
137 |
137 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
28 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
19 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
88 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
125 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
126 |
126 |
$3K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
142 |
$2K |
| D0274 |
Bitewings - four radiographic images |
64 |
64 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
115 |
97 |
$902.52 |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$744.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$426.00 |