| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
886 |
475 |
$90K |
| D1351 |
Sealant - per tooth |
1,133 |
335 |
$54K |
| D1120 |
Prophylaxis - child |
892 |
889 |
$38K |
| D4341 |
|
271 |
136 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,133 |
1,129 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
395 |
223 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
825 |
823 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
256 |
162 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
574 |
567 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
461 |
455 |
$14K |
| D1110 |
Prophylaxis - adult |
271 |
270 |
$13K |
| D0274 |
Bitewings - four radiographic images |
636 |
633 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,151 |
1,008 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
273 |
266 |
$5K |
| D0330 |
Panoramic radiographic image |
185 |
185 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
950 |
817 |
$4K |
| D2394 |
|
16 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$819.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$546.00 |
| D0272 |
Bitewings - two radiographic images |
54 |
54 |
$525.94 |