| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
696 |
332 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
672 |
332 |
$38K |
| D1110 |
Prophylaxis - adult |
1,016 |
999 |
$34K |
| D0274 |
Bitewings - four radiographic images |
976 |
960 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
326 |
130 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
827 |
818 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
249 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
29 |
$4K |
| D2332 |
|
64 |
33 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
341 |
338 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
65 |
$476.72 |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$435.87 |