| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
395 |
226 |
$46K |
| D1120 |
Prophylaxis - child |
1,242 |
1,241 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,387 |
1,387 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,497 |
1,494 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
214 |
138 |
$18K |
| D1110 |
Prophylaxis - adult |
126 |
126 |
$5K |
| D0272 |
Bitewings - two radiographic images |
212 |
212 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$3K |
| D0274 |
Bitewings - four radiographic images |
71 |
71 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
56 |
$748.86 |