| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
724 |
232 |
$80K |
| D1110 |
Prophylaxis - adult |
595 |
576 |
$34K |
| D2332 |
|
254 |
52 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
463 |
447 |
$21K |
| D0330 |
Panoramic radiographic image |
488 |
469 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
646 |
627 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
76 |
$13K |
| D0274 |
Bitewings - four radiographic images |
666 |
647 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
745 |
718 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
170 |
168 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,339 |
650 |
$3K |
| D1351 |
Sealant - per tooth |
103 |
14 |
$3K |
| D4341 |
|
47 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$1K |