| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,042 |
578 |
$132K |
| D1120 |
Prophylaxis - child |
2,283 |
2,283 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
3,305 |
3,305 |
$92K |
| D1110 |
Prophylaxis - adult |
1,461 |
1,461 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,858 |
2,858 |
$70K |
| D0274 |
Bitewings - four radiographic images |
1,123 |
1,123 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
262 |
176 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
654 |
637 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
248 |
238 |
$10K |
| D0330 |
Panoramic radiographic image |
128 |
128 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
150 |
$7K |
| D0272 |
Bitewings - two radiographic images |
267 |
267 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
27 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
420 |
298 |
$4K |
| D1351 |
Sealant - per tooth |
114 |
40 |
$3K |