| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
255 |
164 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
96 |
$18K |
| D1110 |
Prophylaxis - adult |
273 |
266 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
266 |
259 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
39 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
183 |
177 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
283 |
271 |
$3K |
| D0274 |
Bitewings - four radiographic images |
120 |
115 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
78 |
$3K |