| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
37 |
$9K |
| D0330 |
Panoramic radiographic image |
86 |
86 |
$6K |
| D1110 |
Prophylaxis - adult |
109 |
109 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
159 |
159 |
$4K |
| D1120 |
Prophylaxis - child |
91 |
91 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
14 |
$2K |
| D4355 |
|
18 |
18 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$1K |
| D1206 |
Topical application of fluoride varnish |
53 |
53 |
$1K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$593.94 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
27 |
$527.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$360.00 |