| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,468 |
713 |
$104K |
| D1110 |
Prophylaxis - adult |
1,936 |
1,837 |
$99K |
| D1120 |
Prophylaxis - child |
1,524 |
1,409 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
2,546 |
2,407 |
$61K |
| D0330 |
Panoramic radiographic image |
1,179 |
1,070 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,741 |
1,613 |
$48K |
| D1206 |
Topical application of fluoride varnish |
2,501 |
2,376 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,262 |
1,151 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
340 |
197 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
258 |
162 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,027 |
931 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,238 |
1,143 |
$11K |
| D1351 |
Sealant - per tooth |
211 |
30 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
602 |
423 |
$3K |
| D0272 |
Bitewings - two radiographic images |
127 |
80 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$834.82 |