| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
172 |
67 |
$11K |
| D1351 |
Sealant - per tooth |
505 |
51 |
$9K |
| D0330 |
Panoramic radiographic image |
160 |
155 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
284 |
278 |
$7K |
| D1110 |
Prophylaxis - adult |
148 |
145 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
341 |
331 |
$3K |
| D0274 |
Bitewings - four radiographic images |
155 |
154 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
91 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
182 |
157 |
$957.62 |
| D0120 |
Periodic oral evaluation - established patient |
33 |
32 |
$499.44 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$196.43 |