| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
126 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
360 |
360 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
238 |
129 |
$12K |
| D1110 |
Prophylaxis - adult |
149 |
149 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
600 |
594 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
594 |
585 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
115 |
43 |
$6K |
| D1120 |
Prophylaxis - child |
104 |
104 |
$3K |