| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
858 |
311 |
$79K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,162 |
295 |
$76K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
302 |
142 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
396 |
388 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
424 |
418 |
$12K |
| D1110 |
Prophylaxis - adult |
265 |
262 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
368 |
362 |
$9K |
| D1120 |
Prophylaxis - child |
210 |
210 |
$8K |
| D4355 |
|
107 |
103 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
60 |
13 |
$4K |
| D2394 |
|
38 |
13 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
99 |
$2K |
| D1206 |
Topical application of fluoride varnish |
68 |
68 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
57 |
$774.76 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$300.00 |