| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
286 |
286 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
300 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
61 |
$12K |
| D1110 |
Prophylaxis - adult |
174 |
174 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
45 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
32 |
15 |
$3K |
| D2950 |
|
19 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
53 |
53 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$496.86 |