| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
33 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
439 |
253 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
300 |
295 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
198 |
194 |
$3K |
| D1120 |
Prophylaxis - child |
83 |
82 |
$3K |
| D1206 |
Topical application of fluoride varnish |
132 |
132 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
27 |
$3K |
| D1110 |
Prophylaxis - adult |
55 |
55 |
$2K |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
83 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
58 |
$844.22 |
| D0272 |
Bitewings - two radiographic images |
22 |
22 |
$443.30 |