| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
53 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
40 |
$8K |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
26 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
79 |
79 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
48 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$1K |
| D0274 |
Bitewings - four radiographic images |
47 |
46 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
64 |
$817.05 |