| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,265 |
668 |
$164K |
| D1110 |
Prophylaxis - adult |
1,663 |
1,581 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
1,940 |
1,817 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,215 |
1,157 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
313 |
189 |
$21K |
| D0330 |
Panoramic radiographic image |
369 |
348 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,013 |
934 |
$18K |
| D1206 |
Topical application of fluoride varnish |
704 |
688 |
$15K |
| D1120 |
Prophylaxis - child |
327 |
287 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
101 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
128 |
30 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
80 |
$2K |
| D4910 |
|
12 |
12 |
$634.86 |
| D1310 |
|
73 |
63 |
$469.20 |
| D0272 |
Bitewings - two radiographic images |
16 |
15 |
$321.77 |