| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
562 |
362 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
409 |
249 |
$47K |
| D1110 |
Prophylaxis - adult |
510 |
510 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
942 |
942 |
$25K |
| D1120 |
Prophylaxis - child |
564 |
564 |
$21K |
| D1206 |
Topical application of fluoride varnish |
583 |
583 |
$13K |
| D0274 |
Bitewings - four radiographic images |
352 |
352 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
704 |
702 |
$11K |
| D1351 |
Sealant - per tooth |
360 |
150 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
595 |
571 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$3K |
| D0272 |
Bitewings - two radiographic images |
104 |
104 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
92 |
92 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$498.00 |