| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
458 |
240 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
774 |
765 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
149 |
102 |
$18K |
| D1110 |
Prophylaxis - adult |
428 |
420 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
916 |
586 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
778 |
747 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
306 |
287 |
$10K |
| D1120 |
Prophylaxis - child |
371 |
369 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
586 |
581 |
$9K |
| D0330 |
Panoramic radiographic image |
192 |
188 |
$9K |
| D0274 |
Bitewings - four radiographic images |
280 |
271 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
146 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
51 |
$5K |
| D0272 |
Bitewings - two radiographic images |
173 |
173 |
$3K |
| D2332 |
|
21 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
13 |
$1K |