| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
806 |
567 |
$53K |
| D1120 |
Prophylaxis - child |
1,015 |
941 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,453 |
1,304 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
782 |
579 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,008 |
918 |
$24K |
| D0274 |
Bitewings - four radiographic images |
599 |
532 |
$9K |
| D1351 |
Sealant - per tooth |
80 |
66 |
$6K |
| D1110 |
Prophylaxis - adult |
151 |
146 |
$6K |
| D4341 |
|
32 |
12 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
124 |
90 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
73 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
310 |
279 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
74 |
69 |
$1K |
| D0272 |
Bitewings - two radiographic images |
90 |
79 |
$817.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
213 |
171 |
$801.37 |
| D0140 |
Limited oral evaluation - problem focused |
35 |
30 |
$534.60 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$354.90 |