| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
52 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
102 |
37 |
$8K |
| D2332 |
|
94 |
37 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
39 |
$5K |
| D1110 |
Prophylaxis - adult |
103 |
103 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
98 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
44 |
$986.80 |
| D0220 |
Intraoral - periapical first radiographic image |
116 |
109 |
$744.30 |
| D0120 |
Periodic oral evaluation - established patient |
53 |
53 |
$700.16 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$684.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$220.00 |