| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
548 |
416 |
$78K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
527 |
380 |
$60K |
| D1120 |
Prophylaxis - child |
1,184 |
1,163 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,547 |
1,515 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,305 |
1,272 |
$41K |
| D0274 |
Bitewings - four radiographic images |
860 |
843 |
$34K |
| D1110 |
Prophylaxis - adult |
363 |
348 |
$22K |
| D0330 |
Panoramic radiographic image |
286 |
280 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
315 |
311 |
$19K |
| D1351 |
Sealant - per tooth |
259 |
106 |
$11K |
| D0272 |
Bitewings - two radiographic images |
212 |
212 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
120 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
15 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$612.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
15 |
$437.00 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$399.00 |