| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,491 |
956 |
$245K |
| D4341 |
|
687 |
348 |
$118K |
| D1120 |
Prophylaxis - child |
2,819 |
2,732 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
3,784 |
3,654 |
$103K |
| D9110 |
|
1,403 |
1,314 |
$77K |
| D1206 |
Topical application of fluoride varnish |
2,078 |
2,005 |
$53K |
| D0274 |
Bitewings - four radiographic images |
2,426 |
2,328 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
696 |
267 |
$40K |
| D1110 |
Prophylaxis - adult |
1,072 |
1,043 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
3,589 |
3,429 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
186 |
109 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,260 |
3,054 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
628 |
602 |
$14K |
| D1351 |
Sealant - per tooth |
92 |
46 |
$5K |
| D0272 |
Bitewings - two radiographic images |
132 |
123 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$923.52 |