| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,399 |
535 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,668 |
1,641 |
$36K |
| D1110 |
Prophylaxis - adult |
1,070 |
1,031 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
562 |
222 |
$19K |
| D1120 |
Prophylaxis - child |
568 |
568 |
$14K |
| D0274 |
Bitewings - four radiographic images |
1,298 |
1,266 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,085 |
1,066 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,695 |
1,656 |
$7K |
| D1351 |
Sealant - per tooth |
287 |
67 |
$7K |
| D0330 |
Panoramic radiographic image |
154 |
154 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,595 |
1,509 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
150 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
163 |
$2K |
| D2330 |
|
68 |
37 |
$1K |
| D1206 |
Topical application of fluoride varnish |
147 |
137 |
$1K |
| D0272 |
Bitewings - two radiographic images |
88 |
88 |
$704.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$366.00 |