| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,566 |
580 |
$191K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,730 |
524 |
$165K |
| D1120 |
Prophylaxis - child |
1,164 |
1,142 |
$50K |
| D1110 |
Prophylaxis - adult |
706 |
687 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,710 |
1,678 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,268 |
1,246 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
620 |
600 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
359 |
344 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
105 |
67 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
230 |
224 |
$13K |
| D0274 |
Bitewings - four radiographic images |
336 |
325 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
672 |
640 |
$6K |
| D0272 |
Bitewings - two radiographic images |
276 |
270 |
$4K |
| D3120 |
|
116 |
69 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
460 |
440 |
$3K |
| D1330 |
|
210 |
202 |
$1K |