| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,817 |
1,065 |
$136K |
| D1120 |
Prophylaxis - child |
3,482 |
3,367 |
$108K |
| D0330 |
Panoramic radiographic image |
2,184 |
2,109 |
$97K |
| D1110 |
Prophylaxis - adult |
2,007 |
1,952 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
3,300 |
3,003 |
$76K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,579 |
3,477 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,253 |
1,079 |
$48K |
| D0272 |
Bitewings - two radiographic images |
2,232 |
2,155 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
547 |
407 |
$32K |
| D1206 |
Topical application of fluoride varnish |
698 |
667 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
72 |
53 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
538 |
474 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
58 |
56 |
$2K |
| D1351 |
Sealant - per tooth |
86 |
40 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
132 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
14 |
$790.70 |