| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
13 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
13 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
13 |
$865.35 |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$750.86 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$395.25 |
| D0274 |
Bitewings - four radiographic images |
20 |
20 |
$380.00 |
| D0120 |
Periodic oral evaluation - established patient |
18 |
18 |
$290.36 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
12 |
$165.00 |