| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
851 |
371 |
$48K |
| D1110 |
Prophylaxis - adult |
991 |
990 |
$37K |
| D1351 |
Sealant - per tooth |
432 |
188 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
977 |
976 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
776 |
776 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
429 |
229 |
$16K |
| D1120 |
Prophylaxis - child |
399 |
399 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
567 |
567 |
$12K |
| D0274 |
Bitewings - four radiographic images |
507 |
507 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
593 |
593 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
629 |
629 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
733 |
732 |
$6K |
| D2335 |
|
53 |
37 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
29 |
$3K |