| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,441 |
893 |
$170K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,924 |
729 |
$124K |
| D0120 |
Periodic oral evaluation - established patient |
2,728 |
2,727 |
$76K |
| D1110 |
Prophylaxis - adult |
1,498 |
1,498 |
$56K |
| D1120 |
Prophylaxis - child |
1,354 |
1,353 |
$41K |
| D0330 |
Panoramic radiographic image |
707 |
707 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,618 |
1,617 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,451 |
1,451 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,618 |
2,574 |
$13K |
| D1351 |
Sealant - per tooth |
470 |
95 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,292 |
2,264 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
91 |
91 |
$3K |
| D0272 |
Bitewings - two radiographic images |
150 |
150 |
$1K |
| D1206 |
Topical application of fluoride varnish |
47 |
47 |
$846.00 |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$607.00 |
| D1330 |
|
899 |
856 |
$0.00 |