| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
674 |
148 |
$108K |
| D2394 |
|
138 |
55 |
$27K |
| D1206 |
Topical application of fluoride varnish |
674 |
674 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
570 |
570 |
$16K |
| D1120 |
Prophylaxis - child |
533 |
533 |
$15K |
| D0330 |
Panoramic radiographic image |
200 |
200 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
656 |
656 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
716 |
621 |
$7K |
| D0274 |
Bitewings - four radiographic images |
212 |
212 |
$7K |
| D0272 |
Bitewings - two radiographic images |
307 |
307 |
$6K |
| D2335 |
|
35 |
17 |
$5K |
| D1110 |
Prophylaxis - adult |
96 |
96 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
34 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
15 |
$1K |