| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
277 |
86 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
241 |
237 |
$6K |
| D0330 |
Panoramic radiographic image |
120 |
117 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
42 |
$5K |
| D1120 |
Prophylaxis - child |
119 |
119 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
42 |
42 |
$597.80 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$360.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$210.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$180.00 |