| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
720 |
390 |
$44K |
| D1351 |
Sealant - per tooth |
2,144 |
635 |
$37K |
| D1120 |
Prophylaxis - child |
1,804 |
1,748 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
820 |
788 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
538 |
319 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,155 |
1,128 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,937 |
1,881 |
$22K |
| D0274 |
Bitewings - four radiographic images |
749 |
718 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,373 |
855 |
$13K |
| D0272 |
Bitewings - two radiographic images |
668 |
653 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
934 |
900 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
89 |
$1K |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$1K |