| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,152 |
505 |
$107K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
647 |
298 |
$73K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
615 |
326 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
867 |
827 |
$33K |
| D0330 |
Panoramic radiographic image |
449 |
428 |
$22K |
| D1351 |
Sealant - per tooth |
876 |
194 |
$21K |
| D1110 |
Prophylaxis - adult |
629 |
605 |
$21K |
| D1120 |
Prophylaxis - child |
856 |
814 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
865 |
824 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,514 |
904 |
$16K |
| D0274 |
Bitewings - four radiographic images |
570 |
550 |
$15K |
| D4355 |
|
231 |
228 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,017 |
959 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
831 |
790 |
$12K |
| D2331 |
|
83 |
53 |
$6K |
| D0272 |
Bitewings - two radiographic images |
271 |
266 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
112 |
$4K |
| D2394 |
|
20 |
17 |
$3K |
| D1206 |
Topical application of fluoride varnish |
185 |
177 |
$3K |
| D2332 |
|
21 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
14 |
$1K |