| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
69 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
54 |
$9K |
| D1120 |
Prophylaxis - child |
135 |
135 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
159 |
159 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
145 |
145 |
$4K |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
25 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
66 |
$2K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$991.00 |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
66 |
$910.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
39 |
$361.37 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$300.00 |