| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,684 |
720 |
$89K |
| D9920 |
|
711 |
653 |
$75K |
| D1110 |
Prophylaxis - adult |
2,058 |
2,041 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
830 |
511 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,289 |
1,275 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,429 |
1,418 |
$33K |
| D0330 |
Panoramic radiographic image |
742 |
730 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
376 |
199 |
$25K |
| D2740 |
Crown - porcelain/ceramic |
44 |
33 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,245 |
1,229 |
$20K |
| D9110 |
|
552 |
510 |
$16K |
| D1351 |
Sealant - per tooth |
617 |
74 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
686 |
686 |
$13K |
| D1120 |
Prophylaxis - child |
385 |
385 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,345 |
1,229 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
827 |
807 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
53 |
$6K |
| D2331 |
|
104 |
73 |
$6K |
| D2330 |
|
36 |
25 |
$2K |
| D1330 |
|
14 |
14 |
$121.28 |