| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
79 |
39 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
122 |
27 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
39 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
258 |
249 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
76 |
$4K |
| D1110 |
Prophylaxis - adult |
98 |
98 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
161 |
161 |
$3K |
| D1206 |
Topical application of fluoride varnish |
84 |
84 |
$1K |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$357.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$252.00 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
15 |
$99.00 |