| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,661 |
1,094 |
$176K |
| D0120 |
Periodic oral evaluation - established patient |
5,417 |
5,219 |
$136K |
| D1110 |
Prophylaxis - adult |
2,771 |
2,647 |
$103K |
| D1120 |
Prophylaxis - child |
3,432 |
3,299 |
$91K |
| D1206 |
Topical application of fluoride varnish |
4,510 |
4,325 |
$71K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
912 |
604 |
$71K |
| D0140 |
Limited oral evaluation - problem focused |
1,462 |
1,343 |
$51K |
| D0274 |
Bitewings - four radiographic images |
878 |
837 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
575 |
528 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,254 |
1,205 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
663 |
608 |
$9K |
| D1351 |
Sealant - per tooth |
301 |
95 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
38 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
285 |
278 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
68 |
39 |
$4K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |