| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2335 |
|
1,691 |
741 |
$251K |
| D2394 |
|
1,791 |
760 |
$171K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,825 |
913 |
$140K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,068 |
854 |
$98K |
| D2332 |
|
695 |
456 |
$48K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
736 |
511 |
$34K |
| D2330 |
|
785 |
480 |
$31K |
| D1110 |
Prophylaxis - adult |
1,013 |
1,013 |
$27K |
| D2331 |
|
408 |
287 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,140 |
1,139 |
$18K |
| D0330 |
Panoramic radiographic image |
1,046 |
1,044 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
27 |
$2K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$326.70 |