| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
703 |
430 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
723 |
432 |
$68K |
| D0330 |
Panoramic radiographic image |
764 |
733 |
$54K |
| D1110 |
Prophylaxis - adult |
902 |
883 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,256 |
1,244 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,421 |
883 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
964 |
938 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
606 |
601 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,082 |
1,056 |
$26K |
| D1351 |
Sealant - per tooth |
781 |
200 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
102 |
76 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,027 |
1,011 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
254 |
97 |
$17K |
| D1120 |
Prophylaxis - child |
452 |
449 |
$16K |
| D0272 |
Bitewings - two radiographic images |
103 |
103 |
$3K |
| D2331 |
|
17 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$756.00 |