| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
476 |
366 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
572 |
381 |
$64K |
| D1120 |
Prophylaxis - child |
1,112 |
1,109 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,490 |
1,486 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,270 |
1,268 |
$39K |
| D0274 |
Bitewings - four radiographic images |
677 |
676 |
$26K |
| D1110 |
Prophylaxis - adult |
389 |
384 |
$20K |
| D0330 |
Panoramic radiographic image |
255 |
255 |
$17K |
| D0272 |
Bitewings - two radiographic images |
319 |
319 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
113 |
$2K |
| D1351 |
Sealant - per tooth |
40 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$209.00 |