| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
858 |
365 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,118 |
1,093 |
$59K |
| D1110 |
Prophylaxis - adult |
762 |
752 |
$48K |
| D1120 |
Prophylaxis - child |
1,075 |
1,060 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,337 |
1,317 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,706 |
1,678 |
$39K |
| D0330 |
Panoramic radiographic image |
666 |
647 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
169 |
87 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
258 |
117 |
$27K |
| D0274 |
Bitewings - four radiographic images |
1,175 |
1,150 |
$27K |
| D1351 |
Sealant - per tooth |
434 |
63 |
$14K |
| D4341 |
|
48 |
12 |
$3K |
| D1330 |
|
252 |
249 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
110 |
$1K |
| D0272 |
Bitewings - two radiographic images |
44 |
42 |
$669.48 |
| D3120 |
|
18 |
13 |
$630.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$102.00 |