| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
629 |
291 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
791 |
264 |
$74K |
| D1120 |
Prophylaxis - child |
1,077 |
1,058 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,315 |
1,297 |
$38K |
| D1351 |
Sealant - per tooth |
934 |
260 |
$31K |
| D1110 |
Prophylaxis - adult |
451 |
446 |
$26K |
| D1206 |
Topical application of fluoride varnish |
901 |
888 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
619 |
608 |
$14K |
| D0274 |
Bitewings - four radiographic images |
373 |
370 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
141 |
135 |
$7K |
| D0330 |
Panoramic radiographic image |
137 |
137 |
$6K |
| D0272 |
Bitewings - two radiographic images |
300 |
297 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$234.00 |