| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
362 |
259 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
211 |
164 |
$25K |
| D1351 |
Sealant - per tooth |
770 |
234 |
$24K |
| D1110 |
Prophylaxis - adult |
395 |
393 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
723 |
708 |
$19K |
| D1206 |
Topical application of fluoride varnish |
922 |
901 |
$19K |
| D0274 |
Bitewings - four radiographic images |
532 |
503 |
$18K |
| D0330 |
Panoramic radiographic image |
386 |
360 |
$18K |
| D1120 |
Prophylaxis - child |
462 |
449 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
256 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
706 |
642 |
$7K |
| D0272 |
Bitewings - two radiographic images |
224 |
224 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,364 |
357 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
175 |
152 |
$3K |
| D0240 |
|
92 |
37 |
$984.30 |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
14 |
$811.00 |