| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
322 |
139 |
$28K |
| D1110 |
Prophylaxis - adult |
644 |
633 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,272 |
1,267 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,369 |
1,362 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
301 |
132 |
$22K |
| D1120 |
Prophylaxis - child |
556 |
555 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
216 |
$6K |
| D0330 |
Panoramic radiographic image |
77 |
75 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
24 |
$4K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$826.15 |