| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
82 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
267 |
266 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
103 |
103 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
54 |
$6K |
| D1110 |
Prophylaxis - adult |
119 |
119 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
53 |
31 |
$4K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
95 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
20 |
20 |
$611.33 |