| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
534 |
251 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
486 |
195 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
579 |
521 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
266 |
244 |
$6K |
| D1110 |
Prophylaxis - adult |
246 |
235 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
258 |
251 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
316 |
311 |
$3K |
| D1120 |
Prophylaxis - child |
193 |
189 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
493 |
$2K |
| D0274 |
Bitewings - four radiographic images |
149 |
143 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
358 |
329 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
15 |
$737.38 |