| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
621 |
322 |
$36K |
| D1110 |
Prophylaxis - adult |
528 |
513 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
250 |
163 |
$16K |
| D0330 |
Panoramic radiographic image |
372 |
360 |
$16K |
| D1120 |
Prophylaxis - child |
355 |
346 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
654 |
637 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
469 |
$12K |
| D0274 |
Bitewings - four radiographic images |
427 |
420 |
$11K |
| D1206 |
Topical application of fluoride varnish |
678 |
661 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
141 |
87 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
172 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
83 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
329 |
311 |
$3K |
| D1351 |
Sealant - per tooth |
155 |
37 |
$3K |
| D2332 |
|
20 |
12 |
$1K |
| D2394 |
|
17 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
78 |
54 |
$558.75 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
17 |
$230.70 |