| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,334 |
1,408 |
$171K |
| D1110 |
Prophylaxis - adult |
3,239 |
3,176 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
5,493 |
5,366 |
$130K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,086 |
5,937 |
$126K |
| D1120 |
Prophylaxis - child |
3,295 |
3,205 |
$109K |
| D0274 |
Bitewings - four radiographic images |
3,187 |
3,102 |
$85K |
| D0330 |
Panoramic radiographic image |
1,677 |
1,634 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
532 |
335 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
381 |
292 |
$32K |
| D1351 |
Sealant - per tooth |
878 |
305 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
713 |
693 |
$20K |
| D0272 |
Bitewings - two radiographic images |
869 |
837 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
114 |
69 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
519 |
484 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
67 |
$1K |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$533.00 |