| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
559 |
117 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,175 |
1,125 |
$30K |
| D1110 |
Prophylaxis - adult |
545 |
514 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,515 |
1,313 |
$24K |
| D0274 |
Bitewings - four radiographic images |
826 |
793 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
317 |
85 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,226 |
1,188 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,488 |
1,410 |
$16K |
| D1120 |
Prophylaxis - child |
406 |
406 |
$14K |
| D0350 |
|
1,181 |
1,145 |
$13K |
| D1351 |
Sealant - per tooth |
201 |
39 |
$6K |
| D2330 |
|
23 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$435.20 |
| D0603 |
|
1,624 |
1,593 |
$0.00 |