| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
289 |
163 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
765 |
731 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
399 |
385 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
378 |
353 |
$12K |
| D0274 |
Bitewings - four radiographic images |
363 |
346 |
$10K |
| D0330 |
Panoramic radiographic image |
39 |
38 |
$2K |
| D1206 |
Topical application of fluoride varnish |
83 |
83 |
$2K |
| D1351 |
Sealant - per tooth |
71 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
30 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
24 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$356.86 |