| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,272 |
350 |
$91K |
| D1120 |
Prophylaxis - child |
2,768 |
2,214 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,096 |
1,598 |
$60K |
| D1351 |
Sealant - per tooth |
2,636 |
344 |
$60K |
| D0330 |
Panoramic radiographic image |
1,753 |
1,433 |
$59K |
| D0140 |
Limited oral evaluation - problem focused |
1,848 |
1,391 |
$56K |
| D1206 |
Topical application of fluoride varnish |
2,542 |
2,023 |
$48K |
| D0274 |
Bitewings - four radiographic images |
2,204 |
1,752 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
787 |
725 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
77 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
868 |
658 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
26 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
25 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
217 |
76 |
$5K |
| D0272 |
Bitewings - two radiographic images |
85 |
49 |
$963.43 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
25 |
$334.26 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$333.40 |