| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
645 |
522 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
657 |
436 |
$70K |
| D1120 |
Prophylaxis - child |
1,397 |
1,394 |
$59K |
| D1206 |
Topical application of fluoride varnish |
1,704 |
1,701 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,249 |
1,247 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
527 |
527 |
$31K |
| D0330 |
Panoramic radiographic image |
398 |
397 |
$30K |
| D0274 |
Bitewings - four radiographic images |
774 |
773 |
$30K |
| D1110 |
Prophylaxis - adult |
442 |
442 |
$24K |
| D1351 |
Sealant - per tooth |
605 |
258 |
$20K |
| D0272 |
Bitewings - two radiographic images |
407 |
406 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
388 |
388 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
27 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
155 |
149 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
28 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
46 |
46 |
$1K |
| D1310 |
|
30 |
24 |
$0.00 |
| D9993 |
|
26 |
23 |
$0.00 |