| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,345 |
589 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
2,260 |
2,254 |
$85K |
| D1120 |
Prophylaxis - child |
1,597 |
1,593 |
$61K |
| D1110 |
Prophylaxis - adult |
1,106 |
1,098 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,348 |
1,341 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,673 |
1,521 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,891 |
1,856 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
288 |
284 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,099 |
1,096 |
$21K |
| D0272 |
Bitewings - two radiographic images |
979 |
977 |
$20K |
| D0330 |
Panoramic radiographic image |
368 |
366 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
176 |
95 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
171 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0350 |
|
90 |
90 |
$2K |
| D1351 |
Sealant - per tooth |
68 |
26 |
$2K |