| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,106 |
621 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,421 |
1,399 |
$30K |
| D1110 |
Prophylaxis - adult |
871 |
846 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,519 |
1,468 |
$19K |
| D1120 |
Prophylaxis - child |
847 |
818 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
228 |
163 |
$11K |
| D0274 |
Bitewings - four radiographic images |
584 |
569 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
158 |
$5K |
| D1999 |
|
226 |
209 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
367 |
332 |
$3K |
| D0272 |
Bitewings - two radiographic images |
175 |
170 |
$2K |
| D1351 |
Sealant - per tooth |
83 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
188 |
167 |
$403.29 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$237.48 |