| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
372 |
214 |
$52K |
| D7140 |
Extraction, erupted tooth or exposed root |
227 |
100 |
$22K |
| D1110 |
Prophylaxis - adult |
367 |
363 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
161 |
160 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
325 |
323 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
339 |
334 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
442 |
439 |
$10K |
| D0274 |
Bitewings - four radiographic images |
297 |
294 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
38 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
24 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
356 |
349 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$355.14 |