| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,890 |
697 |
$129K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,952 |
676 |
$105K |
| D1110 |
Prophylaxis - adult |
2,202 |
2,177 |
$81K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,368 |
3,332 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
3,639 |
3,610 |
$60K |
| D1120 |
Prophylaxis - child |
1,855 |
1,833 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
4,240 |
4,122 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,835 |
3,779 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,573 |
1,551 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
586 |
572 |
$17K |
| D9310 |
|
108 |
82 |
$7K |
| D9920 |
|
94 |
91 |
$6K |
| D1351 |
Sealant - per tooth |
114 |
24 |
$3K |
| D0272 |
Bitewings - two radiographic images |
124 |
118 |
$2K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$755.86 |
| D9994 |
|
543 |
542 |
$0.00 |