| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
678 |
344 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,432 |
1,325 |
$51K |
| D1120 |
Prophylaxis - child |
1,831 |
1,696 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,882 |
1,720 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
369 |
222 |
$26K |
| D0274 |
Bitewings - four radiographic images |
880 |
800 |
$23K |
| D0330 |
Panoramic radiographic image |
312 |
294 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
242 |
241 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
110 |
$4K |
| D1351 |
Sealant - per tooth |
57 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
14 |
$132.60 |