| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,139 |
811 |
$125K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
795 |
585 |
$120K |
| D1351 |
Sealant - per tooth |
2,770 |
897 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
1,804 |
1,764 |
$87K |
| D1120 |
Prophylaxis - child |
1,704 |
1,660 |
$82K |
| D1206 |
Topical application of fluoride varnish |
2,540 |
2,482 |
$60K |
| D1110 |
Prophylaxis - adult |
849 |
833 |
$45K |
| D0330 |
Panoramic radiographic image |
593 |
593 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
690 |
678 |
$42K |
| D0272 |
Bitewings - two radiographic images |
1,519 |
1,479 |
$24K |
| D0274 |
Bitewings - four radiographic images |
759 |
751 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
78 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
668 |
639 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
136 |
130 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
322 |
307 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
15 |
$2K |