| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
39 |
$4K |
| D1120 |
Prophylaxis - child |
70 |
69 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
88 |
77 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
20 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
65 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
62 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
17 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$1K |
| D1110 |
Prophylaxis - adult |
27 |
20 |
$943.00 |
| D0274 |
Bitewings - four radiographic images |
63 |
52 |
$878.80 |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
125 |
$744.80 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
35 |
$631.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
80 |
$402.80 |