| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
123 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
237 |
115 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
67 |
48 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
94 |
54 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
91 |
91 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
12 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$1K |
| D1120 |
Prophylaxis - child |
22 |
22 |
$902.00 |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$802.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$675.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$264.00 |