| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,953 |
2,080 |
$432K |
| D1110 |
Prophylaxis - adult |
3,975 |
3,974 |
$142K |
| D0120 |
Periodic oral evaluation - established patient |
5,767 |
5,766 |
$112K |
| D0274 |
Bitewings - four radiographic images |
4,237 |
4,237 |
$83K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,575 |
897 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
5,509 |
5,509 |
$53K |
| D1351 |
Sealant - per tooth |
1,194 |
383 |
$50K |
| D1120 |
Prophylaxis - child |
1,515 |
1,515 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,483 |
5,482 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,256 |
2,256 |
$24K |
| D2330 |
|
142 |
37 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
51 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
140 |
140 |
$2K |
| D7111 |
|
21 |
15 |
$450.60 |