| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,441 |
788 |
$187K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
770 |
407 |
$77K |
| D1206 |
Topical application of fluoride varnish |
2,937 |
2,896 |
$74K |
| D1110 |
Prophylaxis - adult |
937 |
928 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,672 |
1,654 |
$50K |
| D1120 |
Prophylaxis - child |
663 |
655 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
485 |
476 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,146 |
1,129 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
347 |
318 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
235 |
228 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,144 |
1,084 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
688 |
664 |
$8K |
| D0330 |
Panoramic radiographic image |
124 |
121 |
$5K |
| D1330 |
|
741 |
726 |
$4K |
| D1351 |
Sealant - per tooth |
121 |
29 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$3K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$420.00 |