| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
46 |
$4K |
| D1110 |
Prophylaxis - adult |
85 |
85 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
30 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
110 |
107 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
189 |
184 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
129 |
123 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
66 |
66 |
$933.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$924.00 |