| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
673 |
454 |
$125K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
725 |
442 |
$107K |
| D1120 |
Prophylaxis - child |
1,228 |
1,191 |
$66K |
| D1206 |
Topical application of fluoride varnish |
1,471 |
1,427 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,396 |
1,349 |
$59K |
| D0330 |
Panoramic radiographic image |
595 |
585 |
$58K |
| D0272 |
Bitewings - two radiographic images |
980 |
951 |
$38K |
| D1110 |
Prophylaxis - adult |
409 |
399 |
$32K |
| D0274 |
Bitewings - four radiographic images |
519 |
515 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
272 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
163 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
441 |
425 |
$11K |
| D1351 |
Sealant - per tooth |
211 |
78 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
127 |
124 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
18 |
$890.00 |