| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,711 |
1,341 |
$111K |
| D1120 |
Prophylaxis - child |
2,183 |
2,182 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,962 |
2,961 |
$70K |
| D1351 |
Sealant - per tooth |
1,132 |
652 |
$62K |
| D0274 |
Bitewings - four radiographic images |
2,777 |
2,775 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
998 |
809 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,281 |
2,280 |
$27K |
| D1110 |
Prophylaxis - adult |
626 |
626 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,701 |
2,681 |
$26K |
| D1206 |
Topical application of fluoride varnish |
490 |
490 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,185 |
2,184 |
$11K |
| D0240 |
|
787 |
572 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
406 |
398 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
56 |
50 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
242 |
238 |
$2K |