| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
376 |
185 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
290 |
184 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
345 |
342 |
$26K |
| D1120 |
Prophylaxis - child |
355 |
352 |
$21K |
| D1206 |
Topical application of fluoride varnish |
533 |
525 |
$19K |
| D1110 |
Prophylaxis - adult |
143 |
142 |
$11K |
| D0274 |
Bitewings - four radiographic images |
176 |
173 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
227 |
221 |
$10K |
| D1351 |
Sealant - per tooth |
209 |
51 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
78 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
164 |
158 |
$4K |
| D0330 |
Panoramic radiographic image |
46 |
45 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
61 |
40 |
$3K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$2K |