| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
939 |
511 |
$124K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,080 |
591 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,444 |
1,418 |
$66K |
| D1110 |
Prophylaxis - adult |
1,019 |
1,002 |
$61K |
| D0330 |
Panoramic radiographic image |
1,306 |
1,277 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
322 |
100 |
$42K |
| D2332 |
|
213 |
110 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
739 |
731 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
107 |
80 |
$18K |
| D0274 |
Bitewings - four radiographic images |
757 |
747 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
676 |
670 |
$16K |
| D2330 |
|
148 |
79 |
$14K |
| D1120 |
Prophylaxis - child |
301 |
300 |
$13K |
| D1351 |
Sealant - per tooth |
197 |
25 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
53 |
$468.68 |
| D1330 |
|
55 |
55 |
$330.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$156.00 |