| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,220 |
574 |
$132K |
| D1120 |
Prophylaxis - child |
2,171 |
2,170 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,784 |
2,782 |
$65K |
| D1206 |
Topical application of fluoride varnish |
2,515 |
2,513 |
$52K |
| D1110 |
Prophylaxis - adult |
921 |
920 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
397 |
234 |
$34K |
| D0274 |
Bitewings - four radiographic images |
778 |
778 |
$22K |
| D0272 |
Bitewings - two radiographic images |
651 |
651 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
865 |
838 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
25 |
$6K |
| D1351 |
Sealant - per tooth |
201 |
80 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
105 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
350 |
289 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$1K |