| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,259 |
1,064 |
$116K |
| D1351 |
Sealant - per tooth |
4,060 |
833 |
$100K |
| D1110 |
Prophylaxis - adult |
2,624 |
2,596 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
4,069 |
4,017 |
$84K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,187 |
552 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,171 |
481 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,884 |
2,845 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,883 |
1,860 |
$53K |
| D1120 |
Prophylaxis - child |
1,705 |
1,680 |
$51K |
| D2330 |
|
839 |
400 |
$43K |
| D1310 |
|
2,129 |
2,123 |
$19K |
| D1330 |
|
2,148 |
2,141 |
$18K |
| D0330 |
Panoramic radiographic image |
394 |
384 |
$14K |
| D9920 |
|
45 |
41 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
240 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
228 |
224 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$2K |
| D0272 |
Bitewings - two radiographic images |
75 |
73 |
$1K |
| D2331 |
|
20 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
116 |
$1K |
| D9110 |
|
16 |
14 |
$532.00 |