| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
249 |
117 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
349 |
334 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
151 |
148 |
$12K |
| D1110 |
Prophylaxis - adult |
261 |
251 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
44 |
24 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
206 |
189 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
75 |
70 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
76 |
76 |
$2K |
| D0274 |
Bitewings - four radiographic images |
59 |
55 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
60 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$143.65 |