| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
322 |
202 |
$20K |
| D1120 |
Prophylaxis - child |
457 |
454 |
$16K |
| D1351 |
Sealant - per tooth |
272 |
96 |
$13K |
| D1110 |
Prophylaxis - adult |
316 |
312 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
186 |
101 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
467 |
467 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
234 |
168 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
452 |
446 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
81 |
58 |
$8K |
| D0274 |
Bitewings - four radiographic images |
372 |
366 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
231 |
231 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
192 |
192 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
701 |
674 |
$5K |
| D1206 |
Topical application of fluoride varnish |
274 |
270 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
682 |
584 |
$3K |
| D0272 |
Bitewings - two radiographic images |
171 |
155 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
83 |
$2K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$336.00 |
| D0240 |
|
29 |
12 |
$126.00 |