| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,755 |
852 |
$186K |
| D0120 |
Periodic oral evaluation - established patient |
4,009 |
3,725 |
$100K |
| D1120 |
Prophylaxis - child |
2,999 |
2,767 |
$79K |
| D1110 |
Prophylaxis - adult |
2,026 |
1,894 |
$74K |
| D1206 |
Topical application of fluoride varnish |
4,107 |
3,772 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,329 |
2,816 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
3,674 |
3,266 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,092 |
943 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,472 |
1,312 |
$42K |
| D0330 |
Panoramic radiographic image |
663 |
604 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
821 |
785 |
$30K |
| D0272 |
Bitewings - two radiographic images |
760 |
733 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
86 |
46 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
171 |
83 |
$11K |
| D1351 |
Sealant - per tooth |
78 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
21 |
$342.66 |