| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
712 |
425 |
$91K |
| D1120 |
Prophylaxis - child |
1,349 |
1,327 |
$64K |
| D1206 |
Topical application of fluoride varnish |
1,941 |
1,911 |
$61K |
| D0272 |
Bitewings - two radiographic images |
1,576 |
1,556 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,326 |
1,310 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
268 |
189 |
$48K |
| D1110 |
Prophylaxis - adult |
661 |
653 |
$48K |
| D0330 |
Panoramic radiographic image |
486 |
483 |
$47K |
| D1351 |
Sealant - per tooth |
1,009 |
302 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
492 |
480 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
212 |
204 |
$14K |
| D0240 |
|
172 |
136 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
194 |
191 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
57 |
55 |
$3K |
| D1330 |
|
14 |
14 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
14 |
$0.00 |