| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
200 |
200 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
66 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
41 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
188 |
188 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
223 |
223 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$3K |
| D1120 |
Prophylaxis - child |
86 |
86 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
16 |
$3K |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$2K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |