| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
33 |
$5K |
| D1110 |
Prophylaxis - adult |
126 |
115 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
140 |
129 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
18 |
$3K |
| D0274 |
Bitewings - four radiographic images |
85 |
77 |
$2K |
| D1120 |
Prophylaxis - child |
22 |
17 |
$660.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
31 |
$616.32 |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$518.00 |
| D9110 |
|
14 |
12 |
$448.00 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
50 |
$404.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
14 |
$301.23 |