| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
309 |
107 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
218 |
85 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
188 |
73 |
$9K |
| D0272 |
Bitewings - two radiographic images |
121 |
118 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
145 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
159 |
143 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$159.00 |