| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,502 |
1,117 |
$294K |
| D1206 |
Topical application of fluoride varnish |
5,269 |
4,176 |
$128K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
851 |
390 |
$125K |
| D1110 |
Prophylaxis - adult |
2,186 |
1,834 |
$123K |
| D1120 |
Prophylaxis - child |
2,943 |
2,259 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
4,132 |
3,381 |
$118K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,076 |
517 |
$98K |
| D1351 |
Sealant - per tooth |
2,593 |
421 |
$86K |
| D8670 |
Periodic orthodontic treatment visit |
973 |
770 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,336 |
950 |
$67K |
| D0274 |
Bitewings - four radiographic images |
2,916 |
2,412 |
$63K |
| D0330 |
Panoramic radiographic image |
1,018 |
768 |
$41K |
| D0272 |
Bitewings - two radiographic images |
1,732 |
1,288 |
$25K |
| D3120 |
|
893 |
325 |
$18K |
| D1330 |
|
1,132 |
917 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
145 |
122 |
$1K |
| D4355 |
|
12 |
12 |
$1K |
| D9310 |
|
12 |
12 |
$576.00 |