| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,093 |
408 |
$61K |
| D1110 |
Prophylaxis - adult |
965 |
965 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
545 |
272 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,096 |
1,096 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
924 |
924 |
$19K |
| D2332 |
|
111 |
40 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
286 |
286 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
569 |
569 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
199 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
40 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
498 |
498 |
$3K |
| D1120 |
Prophylaxis - child |
90 |
90 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
212 |
212 |
$2K |
| D1351 |
Sealant - per tooth |
52 |
12 |
$2K |