| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,553 |
947 |
$184K |
| D1110 |
Prophylaxis - adult |
1,733 |
1,628 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
754 |
506 |
$58K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
296 |
186 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,186 |
1,126 |
$27K |
| D0274 |
Bitewings - four radiographic images |
867 |
809 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
280 |
261 |
$16K |
| D1206 |
Topical application of fluoride varnish |
935 |
884 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
331 |
306 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
216 |
201 |
$3K |
| D1120 |
Prophylaxis - child |
100 |
98 |
$3K |
| D1351 |
Sealant - per tooth |
101 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$373.00 |