| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,250 |
640 |
$147K |
| D1120 |
Prophylaxis - child |
2,365 |
2,365 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
2,840 |
2,839 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,798 |
2,798 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
755 |
422 |
$70K |
| D9920 |
|
800 |
772 |
$40K |
| D1110 |
Prophylaxis - adult |
674 |
674 |
$35K |
| D0272 |
Bitewings - two radiographic images |
856 |
856 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
114 |
57 |
$9K |
| D0240 |
|
276 |
170 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
310 |
308 |
$5K |
| D0274 |
Bitewings - four radiographic images |
121 |
121 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
25 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
277 |
103 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$1K |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$672.00 |