| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
155 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
309 |
309 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
420 |
420 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
99 |
59 |
$8K |
| D1110 |
Prophylaxis - adult |
139 |
137 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
39 |
$2K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$723.30 |
| D0120 |
Periodic oral evaluation - established patient |
40 |
40 |
$704.88 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$703.74 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$535.75 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$366.64 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$216.64 |