| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
530 |
221 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
536 |
201 |
$35K |
| D1120 |
Prophylaxis - child |
567 |
477 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
752 |
609 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
636 |
524 |
$13K |
| D0274 |
Bitewings - four radiographic images |
411 |
335 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
193 |
69 |
$11K |
| D1110 |
Prophylaxis - adult |
313 |
262 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
640 |
432 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
114 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
444 |
300 |
$5K |
| D2394 |
|
19 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
51 |
$2K |
| D1351 |
Sealant - per tooth |
42 |
13 |
$980.00 |