| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
178 |
82 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
164 |
162 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
167 |
163 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
201 |
200 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
40 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
154 |
152 |
$2K |
| D0274 |
Bitewings - four radiographic images |
96 |
96 |
$2K |
| D1120 |
Prophylaxis - child |
76 |
76 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$1K |
| D1206 |
Topical application of fluoride varnish |
30 |
24 |
$324.90 |