| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
429 |
235 |
$59K |
| D7140 |
Extraction, erupted tooth or exposed root |
574 |
215 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
127 |
83 |
$21K |
| D1110 |
Prophylaxis - adult |
416 |
408 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
322 |
310 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
51 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
388 |
382 |
$9K |
| D0274 |
Bitewings - four radiographic images |
285 |
277 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
238 |
224 |
$8K |
| D0330 |
Panoramic radiographic image |
107 |
101 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
262 |
246 |
$3K |