| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
505 |
387 |
$93K |
| D0330 |
Panoramic radiographic image |
672 |
656 |
$64K |
| D1206 |
Topical application of fluoride varnish |
1,419 |
1,389 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
375 |
273 |
$54K |
| D1120 |
Prophylaxis - child |
1,063 |
1,031 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,193 |
1,165 |
$47K |
| D1110 |
Prophylaxis - adult |
432 |
429 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
406 |
394 |
$31K |
| D0272 |
Bitewings - two radiographic images |
850 |
835 |
$30K |
| D0274 |
Bitewings - four radiographic images |
556 |
552 |
$28K |
| D1351 |
Sealant - per tooth |
424 |
116 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
269 |
262 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
507 |
495 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
14 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
91 |
77 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
60 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$676.00 |