| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
29 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
28 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
86 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
44 |
$2K |
| D1110 |
Prophylaxis - adult |
40 |
36 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
71 |
62 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
98 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
30 |
29 |
$852.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$252.42 |