| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,464 |
1,802 |
$291K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,338 |
1,114 |
$173K |
| D1110 |
Prophylaxis - adult |
3,545 |
3,480 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
4,739 |
4,690 |
$108K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,306 |
5,211 |
$80K |
| D0272 |
Bitewings - two radiographic images |
4,954 |
4,861 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
5,884 |
5,694 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
591 |
378 |
$45K |
| D0330 |
Panoramic radiographic image |
1,067 |
1,020 |
$40K |
| D1120 |
Prophylaxis - child |
1,556 |
1,518 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
558 |
522 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,759 |
5,434 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
201 |
196 |
$4K |
| D2332 |
|
17 |
13 |
$971.35 |
| D9920 |
|
12 |
12 |
$327.92 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$260.56 |