| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
526 |
339 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
327 |
198 |
$39K |
| D1110 |
Prophylaxis - adult |
497 |
497 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
934 |
934 |
$24K |
| D1120 |
Prophylaxis - child |
567 |
567 |
$21K |
| D1206 |
Topical application of fluoride varnish |
489 |
489 |
$11K |
| D0274 |
Bitewings - four radiographic images |
321 |
321 |
$11K |
| D1351 |
Sealant - per tooth |
405 |
148 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
647 |
641 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
536 |
508 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
195 |
195 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
83 |
$3K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$680.33 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$454.00 |