| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,608 |
1,306 |
$177K |
| D1110 |
Prophylaxis - adult |
4,145 |
4,018 |
$163K |
| D0120 |
Periodic oral evaluation - established patient |
6,828 |
6,640 |
$155K |
| D1206 |
Topical application of fluoride varnish |
6,250 |
6,084 |
$123K |
| D1120 |
Prophylaxis - child |
2,834 |
2,747 |
$89K |
| D0274 |
Bitewings - four radiographic images |
2,466 |
2,383 |
$61K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,043 |
702 |
$59K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
228 |
121 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,747 |
1,633 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,953 |
904 |
$16K |
| D0272 |
Bitewings - two radiographic images |
807 |
788 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
464 |
446 |
$12K |
| D0330 |
Panoramic radiographic image |
223 |
219 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$878.89 |