| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,098 |
574 |
$168K |
| D1110 |
Prophylaxis - adult |
956 |
864 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,334 |
1,240 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
461 |
293 |
$55K |
| D1120 |
Prophylaxis - child |
697 |
667 |
$42K |
| D0274 |
Bitewings - four radiographic images |
806 |
699 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,102 |
1,050 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
349 |
299 |
$19K |
| D0330 |
Panoramic radiographic image |
213 |
197 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
60 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
235 |
214 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
601 |
545 |
$13K |
| D2740 |
Crown - porcelain/ceramic |
15 |
15 |
$12K |
| D0272 |
Bitewings - two radiographic images |
279 |
268 |
$11K |
| D2331 |
|
23 |
13 |
$4K |
| D1351 |
Sealant - per tooth |
45 |
16 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
12 |
$338.72 |