| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
692 |
248 |
$46K |
| D1120 |
Prophylaxis - child |
619 |
616 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
392 |
392 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
416 |
168 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
337 |
$22K |
| D0350 |
|
1,428 |
473 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
814 |
810 |
$12K |
| D1351 |
Sealant - per tooth |
311 |
79 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
156 |
56 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
111 |
40 |
$9K |
| D0274 |
Bitewings - four radiographic images |
379 |
379 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
162 |
162 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,064 |
476 |
$4K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$3K |
| D2140 |
|
62 |
28 |
$3K |