| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
232 |
160 |
$17K |
| D1120 |
Prophylaxis - child |
297 |
284 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
447 |
423 |
$11K |
| D9110 |
|
211 |
190 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
100 |
$8K |
| D1206 |
Topical application of fluoride varnish |
287 |
276 |
$7K |
| D2752 |
|
19 |
16 |
$4K |
| D4341 |
|
21 |
12 |
$4K |
| D0274 |
Bitewings - four radiographic images |
221 |
204 |
$3K |
| D1110 |
Prophylaxis - adult |
97 |
92 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
114 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
13 |
$2K |
| D2950 |
|
25 |
19 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
137 |
$795.20 |
| D0140 |
Limited oral evaluation - problem focused |
55 |
52 |
$696.60 |
| D0210 |
Intraoral - complete series of radiographic images |
22 |
21 |
$494.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
12 |
$83.60 |