| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
564 |
423 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,212 |
1,210 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
285 |
131 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
332 |
270 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
243 |
241 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
116 |
114 |
$2K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$2K |
| D1206 |
Topical application of fluoride varnish |
39 |
39 |
$881.90 |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
72 |
$456.09 |