| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,775 |
649 |
$170K |
| D4341 |
|
896 |
388 |
$125K |
| D1120 |
Prophylaxis - child |
1,102 |
1,102 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,435 |
1,435 |
$41K |
| D1351 |
Sealant - per tooth |
847 |
287 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
704 |
358 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,073 |
1,073 |
$29K |
| D2332 |
|
243 |
68 |
$26K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
292 |
128 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
938 |
937 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,334 |
1,333 |
$22K |
| D0330 |
Panoramic radiographic image |
604 |
603 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
2,179 |
2,153 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
139 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
584 |
565 |
$11K |
| D1110 |
Prophylaxis - adult |
165 |
165 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,818 |
1,700 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
165 |
162 |
$2K |
| D9110 |
|
22 |
22 |
$1K |
| D2394 |
|
13 |
13 |
$1K |
| D4910 |
|
12 |
12 |
$804.00 |
| D0272 |
Bitewings - two radiographic images |
57 |
57 |
$590.50 |
| D9310 |
|
28 |
28 |
$478.80 |