| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
407 |
187 |
$56K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
217 |
120 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
76 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
352 |
331 |
$13K |
| D2950 |
|
87 |
65 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
132 |
127 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
35 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
139 |
136 |
$5K |
| D1110 |
Prophylaxis - adult |
81 |
77 |
$3K |
| D0274 |
Bitewings - four radiographic images |
104 |
95 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
227 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
113 |
110 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
52 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$390.78 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
13 |
$189.72 |