| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,789 |
721 |
$98K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,235 |
546 |
$91K |
| D1351 |
Sealant - per tooth |
2,584 |
813 |
$52K |
| D1120 |
Prophylaxis - child |
1,638 |
1,612 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
883 |
869 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,060 |
1,043 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,230 |
1,211 |
$18K |
| D1206 |
Topical application of fluoride varnish |
950 |
944 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
865 |
843 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
77 |
58 |
$7K |
| D0274 |
Bitewings - four radiographic images |
370 |
365 |
$7K |
| D2940 |
|
162 |
100 |
$6K |
| D1110 |
Prophylaxis - adult |
144 |
142 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
320 |
304 |
$3K |
| D3120 |
|
87 |
61 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
235 |
168 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
27 |
$2K |
| D2332 |
|
24 |
18 |
$2K |
| D2330 |
|
36 |
25 |
$2K |
| D2335 |
|
18 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
78 |
78 |
$1K |
| D1353 |
|
43 |
16 |
$475.00 |