| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
262 |
262 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
179 |
97 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
59 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
110 |
$5K |
| D1110 |
Prophylaxis - adult |
49 |
49 |
$4K |
| D1120 |
Prophylaxis - child |
73 |
73 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
26 |
13 |
$3K |
| D9430 |
|
92 |
86 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
698 |
134 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
146 |
$2K |
| D4910 |
|
25 |
25 |
$2K |
| D0274 |
Bitewings - four radiographic images |
85 |
85 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$1K |
| D0350 |
|
90 |
44 |
$864.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |