| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
194 |
100 |
$10K |
| D1110 |
Prophylaxis - adult |
217 |
215 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
226 |
224 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
55 |
53 |
$2K |
| D0274 |
Bitewings - four radiographic images |
114 |
112 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
93 |
$1K |
| D1206 |
Topical application of fluoride varnish |
74 |
73 |
$990.00 |
| D1120 |
Prophylaxis - child |
40 |
40 |
$800.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$768.15 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
26 |
$606.05 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$293.54 |