| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
956 |
302 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
526 |
239 |
$30K |
| D1120 |
Prophylaxis - child |
649 |
649 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
839 |
838 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
841 |
841 |
$10K |
| D0272 |
Bitewings - two radiographic images |
652 |
651 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
99 |
73 |
$5K |
| D1110 |
Prophylaxis - adult |
107 |
107 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
40 |
$316.35 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$148.20 |