| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,152 |
582 |
$86K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
893 |
444 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,499 |
1,479 |
$29K |
| D1110 |
Prophylaxis - adult |
742 |
727 |
$27K |
| D1120 |
Prophylaxis - child |
751 |
744 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,109 |
1,092 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
518 |
506 |
$14K |
| D0274 |
Bitewings - four radiographic images |
675 |
664 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
27 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
288 |
280 |
$2K |
| D1351 |
Sealant - per tooth |
32 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
123 |
120 |
$722.57 |
| D3120 |
|
17 |
13 |
$0.00 |