| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
373 |
255 |
$59K |
| D1110 |
Prophylaxis - adult |
633 |
632 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
327 |
327 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
192 |
116 |
$42K |
| D1120 |
Prophylaxis - child |
535 |
533 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
773 |
773 |
$15K |
| D0274 |
Bitewings - four radiographic images |
354 |
354 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
60 |
$12K |
| D1330 |
|
1,256 |
1,251 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,172 |
1,168 |
$9K |
| D1351 |
Sealant - per tooth |
269 |
72 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
299 |
298 |
$8K |
| D0272 |
Bitewings - two radiographic images |
297 |
297 |
$5K |
| D1354 |
|
335 |
83 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
45 |
$643.92 |