| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,119 |
608 |
$128K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,068 |
489 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
1,489 |
1,464 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,742 |
1,716 |
$44K |
| D1110 |
Prophylaxis - adult |
852 |
836 |
$41K |
| D1120 |
Prophylaxis - child |
1,390 |
1,367 |
$36K |
| D1351 |
Sealant - per tooth |
1,117 |
275 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
795 |
785 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,556 |
1,514 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
598 |
592 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,975 |
1,325 |
$11K |
| D0274 |
Bitewings - four radiographic images |
664 |
654 |
$10K |
| D0330 |
Panoramic radiographic image |
170 |
169 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
39 |
$4K |
| D0272 |
Bitewings - two radiographic images |
275 |
272 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
29 |
28 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$776.48 |