| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
276 |
178 |
$18K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
109 |
74 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
315 |
314 |
$12K |
| D1120 |
Prophylaxis - child |
394 |
392 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
597 |
581 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
100 |
79 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
172 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
263 |
261 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
84 |
$6K |
| D0272 |
Bitewings - two radiographic images |
344 |
342 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
307 |
306 |
$3K |
| D9430 |
|
116 |
115 |
$3K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$940.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$252.00 |