| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
277 |
114 |
$16K |
| D1206 |
Topical application of fluoride varnish |
387 |
363 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
144 |
$5K |
| D1110 |
Prophylaxis - adult |
121 |
117 |
$4K |
| D0330 |
Panoramic radiographic image |
104 |
96 |
$3K |
| D1120 |
Prophylaxis - child |
163 |
150 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
38 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
120 |
117 |
$3K |
| D0274 |
Bitewings - four radiographic images |
148 |
139 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
215 |
198 |
$2K |
| D1351 |
Sealant - per tooth |
41 |
12 |
$769.30 |
| D1999 |
|
401 |
311 |
$560.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
204 |
178 |
$447.93 |