| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2721 |
|
64 |
53 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
618 |
345 |
$55K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
606 |
307 |
$41K |
| D0330 |
Panoramic radiographic image |
585 |
564 |
$35K |
| D1110 |
Prophylaxis - adult |
606 |
604 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
628 |
625 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
673 |
650 |
$26K |
| D0274 |
Bitewings - four radiographic images |
469 |
465 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
181 |
180 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
360 |
359 |
$12K |
| D1120 |
Prophylaxis - child |
262 |
262 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
634 |
605 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
58 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
264 |
264 |
$8K |
| D1206 |
Topical application of fluoride varnish |
220 |
220 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
69 |
32 |
$6K |
| D2950 |
|
34 |
29 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
229 |
191 |
$2K |