| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,967 |
1,005 |
$98K |
| D1110 |
Prophylaxis - adult |
1,694 |
1,676 |
$61K |
| D1351 |
Sealant - per tooth |
2,501 |
490 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,239 |
2,217 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
807 |
612 |
$48K |
| D9920 |
|
534 |
524 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,176 |
1,162 |
$33K |
| D1120 |
Prophylaxis - child |
990 |
982 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,383 |
1,369 |
$25K |
| D2330 |
|
480 |
272 |
$24K |
| D0330 |
Panoramic radiographic image |
625 |
623 |
$23K |
| D2332 |
|
264 |
174 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
631 |
626 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,400 |
1,378 |
$11K |
| D9110 |
|
317 |
316 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,177 |
1,161 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
133 |
108 |
$9K |
| D2331 |
|
106 |
66 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
56 |
$4K |
| D0272 |
Bitewings - two radiographic images |
188 |
187 |
$3K |
| D1330 |
|
415 |
414 |
$2K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$276.69 |
| D1999 |
|
34 |
34 |
$0.00 |