| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
108 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
75 |
$21K |
| D1120 |
Prophylaxis - child |
220 |
213 |
$16K |
| D1206 |
Topical application of fluoride varnish |
299 |
289 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
236 |
229 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
87 |
$7K |
| D1110 |
Prophylaxis - adult |
77 |
74 |
$7K |
| D1351 |
Sealant - per tooth |
125 |
41 |
$7K |
| D0274 |
Bitewings - four radiographic images |
101 |
98 |
$7K |
| D0272 |
Bitewings - two radiographic images |
140 |
132 |
$6K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
32 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$482.00 |