| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,373 |
2,062 |
$241K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,119 |
1,441 |
$171K |
| D1110 |
Prophylaxis - adult |
4,708 |
4,700 |
$167K |
| D0120 |
Periodic oral evaluation - established patient |
6,244 |
6,235 |
$125K |
| D0274 |
Bitewings - four radiographic images |
5,452 |
5,451 |
$100K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,734 |
1,321 |
$81K |
| D0220 |
Intraoral - periapical first radiographic image |
6,179 |
6,176 |
$58K |
| D2335 |
|
444 |
351 |
$46K |
| D2332 |
|
564 |
458 |
$42K |
| D1120 |
Prophylaxis - child |
1,122 |
1,121 |
$34K |
| D1351 |
Sealant - per tooth |
455 |
216 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,733 |
4,733 |
$21K |
| D2394 |
|
237 |
202 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
309 |
248 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,193 |
1,193 |
$13K |
| D2331 |
|
50 |
44 |
$3K |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$527.69 |
| D2330 |
|
13 |
13 |
$455.46 |