| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
642 |
251 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
421 |
205 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
762 |
750 |
$19K |
| D1120 |
Prophylaxis - child |
582 |
571 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
869 |
854 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,236 |
729 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
837 |
797 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
251 |
$11K |
| D1110 |
Prophylaxis - adult |
276 |
269 |
$10K |
| D0274 |
Bitewings - four radiographic images |
283 |
278 |
$9K |
| D0330 |
Panoramic radiographic image |
136 |
134 |
$8K |
| D1351 |
Sealant - per tooth |
219 |
58 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
18 |
$5K |
| D0272 |
Bitewings - two radiographic images |
69 |
68 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$572.40 |