| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,483 |
1,503 |
$421K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,462 |
771 |
$133K |
| D1120 |
Prophylaxis - child |
2,766 |
2,764 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
4,027 |
4,024 |
$113K |
| D1206 |
Topical application of fluoride varnish |
3,629 |
3,627 |
$93K |
| D1110 |
Prophylaxis - adult |
1,478 |
1,478 |
$79K |
| D1351 |
Sealant - per tooth |
2,076 |
309 |
$64K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
324 |
215 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
2,048 |
2,039 |
$35K |
| D0274 |
Bitewings - four radiographic images |
865 |
865 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,025 |
1,827 |
$28K |
| D0272 |
Bitewings - two radiographic images |
559 |
558 |
$13K |
| D2950 |
|
21 |
12 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$3K |