| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
332 |
239 |
$81K |
| D1110 |
Prophylaxis - adult |
640 |
620 |
$47K |
| D7140 |
Extraction, erupted tooth or exposed root |
242 |
113 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
391 |
345 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
254 |
216 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
367 |
348 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
40 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
408 |
384 |
$10K |
| D4355 |
|
55 |
29 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
45 |
$3K |
| D0274 |
Bitewings - four radiographic images |
31 |
27 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
53 |
$0.00 |