| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,689 |
2,219 |
$645K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
5,109 |
2,193 |
$496K |
| D1110 |
Prophylaxis - adult |
6,502 |
6,480 |
$285K |
| D0120 |
Periodic oral evaluation - established patient |
8,773 |
8,738 |
$210K |
| D0274 |
Bitewings - four radiographic images |
5,337 |
5,334 |
$122K |
| D1120 |
Prophylaxis - child |
2,296 |
2,288 |
$93K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
775 |
320 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
7,122 |
7,115 |
$60K |
| D0210 |
Intraoral - complete series of radiographic images |
1,103 |
1,096 |
$49K |
| D1351 |
Sealant - per tooth |
600 |
363 |
$43K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,996 |
6,993 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,577 |
2,565 |
$34K |
| D1206 |
Topical application of fluoride varnish |
537 |
537 |
$15K |
| D0272 |
Bitewings - two radiographic images |
296 |
295 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$402.22 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$381.12 |