| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
207 |
110 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
104 |
61 |
$10K |
| D1120 |
Prophylaxis - child |
192 |
192 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
199 |
199 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
199 |
199 |
$5K |
| D1110 |
Prophylaxis - adult |
81 |
81 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
103 |
$2K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
94 |
$1K |