| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
521 |
190 |
$26K |
| D1351 |
Sealant - per tooth |
1,062 |
151 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
391 |
143 |
$25K |
| D1110 |
Prophylaxis - adult |
634 |
632 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
362 |
174 |
$21K |
| D0274 |
Bitewings - four radiographic images |
731 |
729 |
$20K |
| D9920 |
|
192 |
191 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
481 |
481 |
$14K |
| D0330 |
Panoramic radiographic image |
292 |
290 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
369 |
368 |
$9K |
| D2332 |
|
98 |
32 |
$6K |
| D1206 |
Topical application of fluoride varnish |
385 |
385 |
$6K |
| D1120 |
Prophylaxis - child |
180 |
180 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
638 |
613 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
526 |
515 |
$4K |
| D0602 |
|
265 |
265 |
$2K |
| D9110 |
|
56 |
54 |
$2K |
| D1330 |
|
304 |
304 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
35 |
35 |
$1K |
| D1310 |
|
32 |
32 |
$45.00 |