| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
640 |
366 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
401 |
169 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
620 |
611 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
509 |
493 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,068 |
795 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
123 |
84 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
229 |
222 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
850 |
829 |
$9K |
| D1110 |
Prophylaxis - adult |
181 |
181 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
25 |
$3K |
| D0270 |
|
292 |
287 |
$3K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$441.19 |