| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
969 |
590 |
$82K |
| D1120 |
Prophylaxis - child |
1,842 |
1,841 |
$80K |
| D1110 |
Prophylaxis - adult |
1,792 |
1,792 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
3,164 |
3,163 |
$79K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,948 |
1,947 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
536 |
337 |
$37K |
| D0274 |
Bitewings - four radiographic images |
2,468 |
2,466 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
3,319 |
3,306 |
$17K |
| D1351 |
Sealant - per tooth |
620 |
69 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,035 |
3,035 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
211 |
211 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
200 |
200 |
$5K |
| D1206 |
Topical application of fluoride varnish |
107 |
107 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
67 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$770.00 |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$620.00 |