| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
783 |
208 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
822 |
771 |
$30K |
| D1110 |
Prophylaxis - adult |
479 |
453 |
$21K |
| D2140 |
|
505 |
136 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
928 |
861 |
$18K |
| D2332 |
|
154 |
75 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
41 |
$577.57 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$557.95 |
| D1120 |
Prophylaxis - child |
26 |
25 |
$207.00 |