| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
820 |
485 |
$36K |
| D1110 |
Prophylaxis - adult |
1,150 |
1,085 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
652 |
418 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,634 |
1,549 |
$20K |
| D0274 |
Bitewings - four radiographic images |
710 |
666 |
$11K |
| D1120 |
Prophylaxis - child |
558 |
532 |
$10K |
| D1206 |
Topical application of fluoride varnish |
743 |
699 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
383 |
351 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
43 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
299 |
280 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
48 |
$918.69 |
| D0272 |
Bitewings - two radiographic images |
55 |
54 |
$644.77 |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$627.54 |