| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
970 |
506 |
$119K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
952 |
525 |
$86K |
| D1120 |
Prophylaxis - child |
1,116 |
1,116 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,374 |
1,374 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,234 |
1,234 |
$29K |
| D1110 |
Prophylaxis - adult |
481 |
481 |
$24K |
| D0274 |
Bitewings - four radiographic images |
502 |
502 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,511 |
560 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
642 |
641 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
37 |
$7K |
| D1351 |
Sealant - per tooth |
213 |
75 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
126 |
$5K |
| D0272 |
Bitewings - two radiographic images |
119 |
119 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$2K |
| D0240 |
|
24 |
12 |
$528.00 |