| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,174 |
550 |
$118K |
| D1110 |
Prophylaxis - adult |
1,471 |
1,469 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,251 |
2,244 |
$54K |
| D1206 |
Topical application of fluoride varnish |
2,465 |
2,449 |
$51K |
| D1120 |
Prophylaxis - child |
1,313 |
1,303 |
$47K |
| D0274 |
Bitewings - four radiographic images |
718 |
718 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
423 |
421 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
161 |
93 |
$14K |
| D0330 |
Panoramic radiographic image |
156 |
156 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
25 |
$5K |
| D1351 |
Sealant - per tooth |
194 |
41 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
132 |
$2K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$336.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
29 |
$301.86 |