| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,774 |
1,135 |
$124K |
| D1120 |
Prophylaxis - child |
4,482 |
4,359 |
$104K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,586 |
5,430 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
4,804 |
4,659 |
$76K |
| D1351 |
Sealant - per tooth |
3,747 |
1,371 |
$73K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,210 |
883 |
$64K |
| D0272 |
Bitewings - two radiographic images |
2,648 |
2,575 |
$42K |
| D1110 |
Prophylaxis - adult |
1,101 |
1,069 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
846 |
836 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
91 |
57 |
$5K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$460.69 |
| D1206 |
Topical application of fluoride varnish |
22 |
22 |
$358.86 |