| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
412 |
209 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,050 |
1,049 |
$25K |
| D1120 |
Prophylaxis - child |
604 |
603 |
$21K |
| D1110 |
Prophylaxis - adult |
475 |
475 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
308 |
166 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
836 |
835 |
$18K |
| D0274 |
Bitewings - four radiographic images |
207 |
207 |
$7K |
| D1351 |
Sealant - per tooth |
222 |
46 |
$6K |
| D0272 |
Bitewings - two radiographic images |
119 |
119 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$945.00 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
46 |
$419.50 |