| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,167 |
476 |
$80K |
| D1110 |
Prophylaxis - adult |
1,604 |
1,443 |
$72K |
| D0274 |
Bitewings - four radiographic images |
1,290 |
1,156 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,476 |
1,325 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
824 |
734 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
343 |
199 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,112 |
838 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,290 |
1,122 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
199 |
95 |
$14K |
| D1206 |
Topical application of fluoride varnish |
660 |
616 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
360 |
318 |
$11K |
| D0330 |
Panoramic radiographic image |
163 |
151 |
$9K |
| D1120 |
Prophylaxis - child |
300 |
267 |
$9K |
| D1351 |
Sealant - per tooth |
67 |
18 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
61 |
$645.80 |
| D0272 |
Bitewings - two radiographic images |
14 |
13 |
$345.45 |