| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,406 |
729 |
$169K |
| D1120 |
Prophylaxis - child |
2,715 |
2,685 |
$115K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,055 |
592 |
$98K |
| D1206 |
Topical application of fluoride varnish |
3,541 |
3,496 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
2,909 |
2,873 |
$84K |
| D1351 |
Sealant - per tooth |
1,928 |
359 |
$64K |
| D1110 |
Prophylaxis - adult |
989 |
971 |
$57K |
| D0274 |
Bitewings - four radiographic images |
1,479 |
1,459 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
576 |
567 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
3,044 |
2,985 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,156 |
1,145 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,835 |
2,800 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
178 |
166 |
$8K |
| D1330 |
|
1,079 |
1,069 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$1K |
| D7111 |
|
24 |
18 |
$648.00 |
| D0330 |
Panoramic radiographic image |
15 |
14 |
$630.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
13 |
$600.00 |