| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
900 |
477 |
$122K |
| D1110 |
Prophylaxis - adult |
1,308 |
1,291 |
$85K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
358 |
235 |
$61K |
| D0330 |
Panoramic radiographic image |
1,050 |
1,029 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,882 |
1,849 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
840 |
822 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
367 |
201 |
$39K |
| D1351 |
Sealant - per tooth |
865 |
120 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,266 |
1,245 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
898 |
882 |
$28K |
| D1120 |
Prophylaxis - child |
481 |
470 |
$22K |
| D2394 |
|
83 |
52 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
205 |
198 |
$9K |
| D3120 |
|
140 |
100 |
$5K |
| D1330 |
|
611 |
601 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
172 |
$2K |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$607.17 |