| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,549 |
832 |
$193K |
| D0120 |
Periodic oral evaluation - established patient |
4,600 |
4,534 |
$136K |
| D1110 |
Prophylaxis - adult |
2,205 |
2,168 |
$132K |
| D1120 |
Prophylaxis - child |
3,003 |
2,954 |
$131K |
| D1351 |
Sealant - per tooth |
3,302 |
812 |
$116K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,088 |
5,008 |
$116K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
407 |
187 |
$65K |
| D0274 |
Bitewings - four radiographic images |
2,063 |
2,029 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
255 |
173 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
271 |
266 |
$14K |
| D0330 |
Panoramic radiographic image |
274 |
269 |
$12K |
| D0272 |
Bitewings - two radiographic images |
190 |
186 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
24 |
$222.91 |