| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,867 |
1,106 |
$112K |
| D1110 |
Prophylaxis - adult |
2,626 |
2,605 |
$91K |
| D0274 |
Bitewings - four radiographic images |
3,161 |
3,138 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,827 |
2,808 |
$62K |
| D1351 |
Sealant - per tooth |
2,174 |
444 |
$59K |
| D0330 |
Panoramic radiographic image |
1,328 |
1,316 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,689 |
1,674 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
722 |
541 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
532 |
420 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
483 |
190 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,417 |
1,409 |
$25K |
| D1120 |
Prophylaxis - child |
763 |
759 |
$22K |
| D0272 |
Bitewings - two radiographic images |
959 |
951 |
$15K |
| D2331 |
|
184 |
140 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
201 |
197 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,009 |
993 |
$7K |
| D9110 |
|
71 |
71 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
188 |
177 |
$2K |
| D2332 |
|
21 |
13 |
$1K |
| D2330 |
|
19 |
14 |
$963.50 |
| D2335 |
|
15 |
12 |
$910.00 |