| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,030 |
2,736 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
978 |
517 |
$92K |
| D1120 |
Prophylaxis - child |
2,912 |
2,651 |
$65K |
| D1351 |
Sealant - per tooth |
2,594 |
431 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,735 |
2,520 |
$47K |
| D0330 |
Panoramic radiographic image |
1,098 |
997 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
604 |
528 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
79 |
52 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
108 |
57 |
$7K |
| D0274 |
Bitewings - four radiographic images |
417 |
360 |
$7K |
| D0272 |
Bitewings - two radiographic images |
339 |
317 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
25 |
12 |
$455.00 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
26 |
$287.40 |