| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,663 |
828 |
$245K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,025 |
880 |
$240K |
| D1120 |
Prophylaxis - child |
2,829 |
2,741 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
4,017 |
3,906 |
$115K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,311 |
4,184 |
$96K |
| D1110 |
Prophylaxis - adult |
1,601 |
1,555 |
$92K |
| D1351 |
Sealant - per tooth |
2,056 |
468 |
$68K |
| D0330 |
Panoramic radiographic image |
800 |
768 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
783 |
725 |
$33K |
| D8670 |
Periodic orthodontic treatment visit |
274 |
251 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
391 |
380 |
$20K |
| D1330 |
|
2,595 |
2,513 |
$15K |
| D0274 |
Bitewings - four radiographic images |
656 |
630 |
$15K |
| D0272 |
Bitewings - two radiographic images |
800 |
769 |
$12K |
| D3120 |
|
16 |
15 |
$560.00 |