| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,090 |
476 |
$138K |
| D1110 |
Prophylaxis - adult |
1,300 |
1,285 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
2,009 |
1,981 |
$59K |
| D8670 |
Periodic orthodontic treatment visit |
731 |
712 |
$53K |
| D0274 |
Bitewings - four radiographic images |
2,336 |
2,296 |
$53K |
| D1206 |
Topical application of fluoride varnish |
1,726 |
1,704 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
207 |
106 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,752 |
2,670 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
567 |
548 |
$26K |
| D8999 |
|
44 |
44 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,430 |
2,367 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
64 |
$13K |
| D9310 |
|
251 |
241 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
460 |
456 |
$11K |
| D1120 |
Prophylaxis - child |
168 |
168 |
$8K |
| D8660 |
|
46 |
42 |
$6K |
| D1330 |
|
557 |
556 |
$3K |
| D1351 |
Sealant - per tooth |
78 |
14 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
24 |
$1K |
| D3120 |
|
30 |
15 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$741.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$393.84 |