| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
80 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
27 |
$3K |
| D1120 |
Prophylaxis - child |
90 |
89 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
157 |
156 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
129 |
$3K |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
24 |
$2K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$952.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$373.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$115.00 |