| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
991 |
476 |
$119K |
| D1120 |
Prophylaxis - child |
1,326 |
1,324 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,643 |
1,637 |
$43K |
| D1110 |
Prophylaxis - adult |
794 |
791 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,614 |
1,609 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
348 |
219 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,332 |
1,311 |
$20K |
| D0274 |
Bitewings - four radiographic images |
641 |
636 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
425 |
424 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
98 |
56 |
$14K |
| D1351 |
Sealant - per tooth |
455 |
164 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,084 |
1,040 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
190 |
186 |
$8K |
| D0272 |
Bitewings - two radiographic images |
348 |
348 |
$8K |
| D0330 |
Panoramic radiographic image |
85 |
85 |
$5K |
| D2331 |
|
24 |
12 |
$2K |