| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
764 |
763 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
605 |
307 |
$40K |
| D1120 |
Prophylaxis - child |
810 |
808 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
553 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,006 |
1,110 |
$12K |
| D0274 |
Bitewings - four radiographic images |
533 |
531 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
739 |
738 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
26 |
$3K |
| D0272 |
Bitewings - two radiographic images |
197 |
197 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$156.00 |