| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,227 |
563 |
$105K |
| D1120 |
Prophylaxis - child |
4,277 |
3,623 |
$96K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,306 |
1,815 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,935 |
3,314 |
$50K |
| D0330 |
Panoramic radiographic image |
1,456 |
1,211 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,816 |
1,692 |
$43K |
| D1351 |
Sealant - per tooth |
1,248 |
286 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,436 |
1,162 |
$18K |
| D0274 |
Bitewings - four radiographic images |
769 |
662 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
83 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
86 |
73 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
72 |
$942.18 |