| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
283 |
104 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
239 |
89 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
87 |
23 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
169 |
162 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
264 |
$8K |
| D1110 |
Prophylaxis - adult |
58 |
57 |
$2K |