| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
32 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
87 |
85 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
153 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
15 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
15 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
36 |
36 |
$654.42 |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$437.40 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$120.76 |