| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
200 |
122 |
$28K |
| D1110 |
Prophylaxis - adult |
358 |
358 |
$24K |
| D1206 |
Topical application of fluoride varnish |
596 |
596 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
447 |
447 |
$14K |
| D1120 |
Prophylaxis - child |
279 |
279 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
189 |
189 |
$11K |
| D0330 |
Panoramic radiographic image |
226 |
226 |
$10K |
| D2750 |
|
18 |
16 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
33 |
$8K |
| D0274 |
Bitewings - four radiographic images |
292 |
292 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
142 |
137 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
518 |
514 |
$6K |
| D1351 |
Sealant - per tooth |
85 |
15 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
18 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
16 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
352 |
352 |
$3K |
| D2950 |
|
19 |
17 |
$2K |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$2K |
| D1330 |
|
91 |
91 |
$655.20 |