| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
515 |
203 |
$80K |
| D0274 |
Bitewings - four radiographic images |
1,366 |
1,340 |
$50K |
| D1110 |
Prophylaxis - adult |
852 |
836 |
$48K |
| D0330 |
Panoramic radiographic image |
614 |
602 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
740 |
712 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
298 |
123 |
$37K |
| D1120 |
Prophylaxis - child |
850 |
819 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,412 |
1,368 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,011 |
989 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
287 |
284 |
$12K |
| D0272 |
Bitewings - two radiographic images |
322 |
308 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
406 |
370 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
224 |
198 |
$8K |
| D1351 |
Sealant - per tooth |
193 |
42 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
26 |
$562.00 |