| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,209 |
720 |
$243K |
| D0120 |
Periodic oral evaluation - established patient |
4,011 |
3,804 |
$157K |
| D1110 |
Prophylaxis - adult |
2,277 |
2,211 |
$153K |
| D1206 |
Topical application of fluoride varnish |
4,237 |
4,093 |
$139K |
| D1120 |
Prophylaxis - child |
2,147 |
2,078 |
$109K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
625 |
410 |
$96K |
| D1351 |
Sealant - per tooth |
1,986 |
452 |
$92K |
| D0274 |
Bitewings - four radiographic images |
1,608 |
1,560 |
$83K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
260 |
185 |
$63K |
| D0330 |
Panoramic radiographic image |
752 |
725 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
349 |
298 |
$20K |
| D0272 |
Bitewings - two radiographic images |
415 |
402 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
400 |
375 |
$9K |
| D9110 |
|
13 |
13 |
$1K |
| D0602 |
|
2,254 |
2,188 |
$0.00 |
| D0603 |
|
1,155 |
1,120 |
$0.00 |
| D0601 |
|
475 |
462 |
$0.00 |