| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,086 |
994 |
$151K |
| D1110 |
Prophylaxis - adult |
2,986 |
2,938 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
3,805 |
3,741 |
$91K |
| D1120 |
Prophylaxis - child |
2,380 |
2,346 |
$79K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,712 |
3,659 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,116 |
606 |
$66K |
| D0274 |
Bitewings - four radiographic images |
2,362 |
2,329 |
$63K |
| D0330 |
Panoramic radiographic image |
1,255 |
1,236 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,421 |
1,405 |
$41K |
| D1206 |
Topical application of fluoride varnish |
921 |
908 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
121 |
85 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
351 |
345 |
$8K |
| D0272 |
Bitewings - two radiographic images |
427 |
420 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
572 |
561 |
$7K |
| D1351 |
Sealant - per tooth |
116 |
38 |
$3K |
| D2331 |
|
19 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
64 |
$818.15 |