| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
249 |
128 |
$24K |
| D1110 |
Prophylaxis - adult |
478 |
448 |
$18K |
| D1120 |
Prophylaxis - child |
304 |
302 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
510 |
500 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
443 |
430 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
268 |
254 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
35 |
$6K |
| D1351 |
Sealant - per tooth |
129 |
25 |
$4K |
| D0274 |
Bitewings - four radiographic images |
242 |
226 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
16 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
49 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
183 |
171 |
$1K |
| D1330 |
|
180 |
174 |
$1K |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$270.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
15 |
$135.00 |
| D1999 |
|
190 |
154 |
$0.00 |