| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,406 |
668 |
$67K |
| D1110 |
Prophylaxis - adult |
1,717 |
1,705 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,177 |
1,170 |
$55K |
| D1120 |
Prophylaxis - child |
1,837 |
1,829 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
2,351 |
2,337 |
$33K |
| D1330 |
|
3,546 |
3,525 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
241 |
155 |
$22K |
| D0330 |
Panoramic radiographic image |
254 |
254 |
$18K |
| D1351 |
Sealant - per tooth |
2,303 |
620 |
$8K |
| D1206 |
Topical application of fluoride varnish |
3,506 |
3,487 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$5K |
| D0274 |
Bitewings - four radiographic images |
960 |
954 |
$5K |
| D0272 |
Bitewings - two radiographic images |
995 |
992 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
286 |
271 |
$933.02 |
| D0140 |
Limited oral evaluation - problem focused |
51 |
50 |
$787.47 |
| D1999 |
|
1,207 |
1,065 |
$726.85 |