| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
298 |
113 |
$19K |
| D1120 |
Prophylaxis - child |
567 |
538 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
222 |
103 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
652 |
623 |
$17K |
| D1110 |
Prophylaxis - adult |
320 |
306 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
688 |
655 |
$13K |
| D0330 |
Panoramic radiographic image |
223 |
218 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
194 |
$9K |
| D0272 |
Bitewings - two radiographic images |
440 |
424 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
64 |
18 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
66 |
$910.09 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$461.88 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
29 |
$330.00 |