| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
390 |
387 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
157 |
99 |
$9K |
| D1110 |
Prophylaxis - adult |
209 |
201 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
751 |
715 |
$6K |
| D0274 |
Bitewings - four radiographic images |
222 |
214 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
168 |
$4K |
| D1120 |
Prophylaxis - child |
60 |
60 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
155 |
151 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
399 |
309 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
25 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$907.26 |
| D1206 |
Topical application of fluoride varnish |
63 |
63 |
$825.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$674.88 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$672.82 |