| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,770 |
851 |
$140K |
| D1206 |
Topical application of fluoride varnish |
3,511 |
3,463 |
$84K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,259 |
625 |
$76K |
| D1110 |
Prophylaxis - adult |
2,127 |
2,112 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,880 |
2,864 |
$67K |
| D1120 |
Prophylaxis - child |
1,206 |
1,203 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,254 |
1,249 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
343 |
342 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
27 |
$5K |
| D0272 |
Bitewings - two radiographic images |
406 |
405 |
$4K |
| D0330 |
Panoramic radiographic image |
177 |
177 |
$4K |
| D1999 |
|
358 |
349 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
63 |
$3K |
| D1351 |
Sealant - per tooth |
68 |
28 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
59 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
14 |
$86.64 |