| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
553 |
195 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
516 |
194 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
841 |
841 |
$23K |
| D1120 |
Prophylaxis - child |
448 |
448 |
$11K |
| D0274 |
Bitewings - four radiographic images |
631 |
631 |
$9K |
| D1110 |
Prophylaxis - adult |
286 |
286 |
$9K |
| D0330 |
Panoramic radiographic image |
196 |
196 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
524 |
524 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
945 |
940 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
829 |
828 |
$4K |
| D1351 |
Sealant - per tooth |
111 |
27 |
$3K |
| D0272 |
Bitewings - two radiographic images |
119 |
118 |
$952.00 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$522.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$512.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$276.00 |