| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
667 |
397 |
$87K |
| D1110 |
Prophylaxis - adult |
1,001 |
980 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,673 |
1,647 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
624 |
614 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
936 |
925 |
$29K |
| D1120 |
Prophylaxis - child |
443 |
434 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
265 |
264 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
52 |
$13K |
| D0274 |
Bitewings - four radiographic images |
240 |
239 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
116 |
114 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
27 |
$4K |
| D1330 |
|
492 |
482 |
$3K |
| D1351 |
Sealant - per tooth |
94 |
16 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
202 |
198 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
32 |
$328.00 |