| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,155 |
1,023 |
$212K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,550 |
892 |
$198K |
| D0120 |
Periodic oral evaluation - established patient |
2,447 |
2,447 |
$70K |
| D1120 |
Prophylaxis - child |
797 |
797 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
198 |
146 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
574 |
574 |
$26K |
| D1206 |
Topical application of fluoride varnish |
898 |
898 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
437 |
435 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
102 |
102 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
454 |
451 |
$8K |
| D0272 |
Bitewings - two radiographic images |
282 |
282 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
68 |
43 |
$6K |
| D1351 |
Sealant - per tooth |
183 |
25 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
50 |
$5K |
| D1110 |
Prophylaxis - adult |
81 |
81 |
$4K |
| D0240 |
|
128 |
65 |
$3K |