| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,049 |
633 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,185 |
1,185 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
491 |
316 |
$26K |
| D1110 |
Prophylaxis - adult |
461 |
461 |
$20K |
| D0274 |
Bitewings - four radiographic images |
714 |
713 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
305 |
149 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
950 |
943 |
$16K |
| D1120 |
Prophylaxis - child |
383 |
383 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
140 |
140 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
272 |
268 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
661 |
650 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
44 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
13 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$330.00 |