| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,360 |
268 |
$224K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
232 |
81 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,195 |
1,176 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
780 |
761 |
$23K |
| D1120 |
Prophylaxis - child |
451 |
440 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
394 |
366 |
$18K |
| D1110 |
Prophylaxis - adult |
255 |
255 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
167 |
164 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
28 |
$6K |
| D1351 |
Sealant - per tooth |
114 |
15 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$3K |
| D1330 |
|
251 |
246 |
$2K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$625.82 |