| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,743 |
838 |
$86K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,150 |
463 |
$72K |
| D1110 |
Prophylaxis - adult |
2,013 |
2,004 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,055 |
595 |
$62K |
| D0330 |
Panoramic radiographic image |
1,282 |
1,278 |
$46K |
| D1351 |
Sealant - per tooth |
1,881 |
291 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,498 |
1,495 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,332 |
1,326 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,289 |
1,286 |
$25K |
| D2330 |
|
475 |
249 |
$23K |
| D2331 |
|
309 |
174 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
373 |
373 |
$7K |
| D1120 |
Prophylaxis - child |
222 |
222 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
93 |
73 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
428 |
419 |
$3K |
| D0272 |
Bitewings - two radiographic images |
84 |
84 |
$1K |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$324.00 |