| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
375 |
196 |
$24K |
| D1110 |
Prophylaxis - adult |
609 |
592 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
324 |
203 |
$19K |
| D0274 |
Bitewings - four radiographic images |
671 |
651 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
481 |
471 |
$10K |
| D0330 |
Panoramic radiographic image |
216 |
208 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
359 |
350 |
$7K |
| D1206 |
Topical application of fluoride varnish |
223 |
223 |
$4K |
| D1120 |
Prophylaxis - child |
119 |
119 |
$4K |
| D1351 |
Sealant - per tooth |
96 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
91 |
$800.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$456.32 |
| D1999 |
|
17 |
17 |
$0.00 |