| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
693 |
353 |
$71K |
| D1110 |
Prophylaxis - adult |
668 |
651 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
430 |
234 |
$26K |
| D0330 |
Panoramic radiographic image |
535 |
516 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,212 |
1,183 |
$25K |
| D0274 |
Bitewings - four radiographic images |
739 |
730 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,393 |
1,333 |
$21K |
| D1206 |
Topical application of fluoride varnish |
955 |
917 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
485 |
460 |
$14K |
| D1120 |
Prophylaxis - child |
448 |
436 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,536 |
899 |
$12K |
| D1320 |
|
333 |
332 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
702 |
702 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
40 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
192 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
14 |
$2K |
| D2330 |
|
34 |
16 |
$2K |
| D0350 |
|
60 |
60 |
$2K |
| D0603 |
|
14 |
14 |
$128.10 |