| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
411 |
237 |
$35K |
| D1110 |
Prophylaxis - adult |
624 |
586 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
761 |
700 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
445 |
393 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
935 |
893 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
107 |
46 |
$21K |
| D0274 |
Bitewings - four radiographic images |
268 |
262 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
314 |
297 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
159 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
28 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
306 |
221 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$999.00 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$483.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$297.72 |