| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,507 |
843 |
$190K |
| D1120 |
Prophylaxis - child |
2,854 |
2,806 |
$125K |
| D1206 |
Topical application of fluoride varnish |
4,890 |
4,806 |
$122K |
| D1110 |
Prophylaxis - adult |
1,881 |
1,848 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
3,630 |
3,582 |
$110K |
| D1351 |
Sealant - per tooth |
2,441 |
392 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,352 |
1,315 |
$71K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
713 |
422 |
$69K |
| D0330 |
Panoramic radiographic image |
631 |
620 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
389 |
379 |
$22K |
| D0274 |
Bitewings - four radiographic images |
853 |
838 |
$20K |
| D1330 |
|
2,093 |
2,061 |
$13K |
| D4341 |
|
103 |
43 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
41 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
156 |
155 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
288 |
283 |
$3K |
| D0272 |
Bitewings - two radiographic images |
103 |
99 |
$2K |