| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,097 |
404 |
$17K |
| D1110 |
Prophylaxis - adult |
1,119 |
1,111 |
$14K |
| D1206 |
Topical application of fluoride varnish |
1,368 |
1,360 |
$9K |
| D0274 |
Bitewings - four radiographic images |
989 |
983 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
1,097 |
1,091 |
$8K |
| D9920 |
|
270 |
262 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
753 |
747 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
426 |
257 |
$5K |
| D1120 |
Prophylaxis - child |
640 |
639 |
$5K |
| D0330 |
Panoramic radiographic image |
508 |
506 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
386 |
378 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
994 |
976 |
$3K |
| D1330 |
|
548 |
536 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
891 |
759 |
$2K |
| D2331 |
|
56 |
28 |
$1K |
| D0272 |
Bitewings - two radiographic images |
133 |
133 |
$1K |
| D1351 |
Sealant - per tooth |
1,446 |
242 |
$244.53 |
| D2330 |
|
17 |
13 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
14 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
27 |
$0.00 |