| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
499 |
301 |
$36K |
| D1110 |
Prophylaxis - adult |
789 |
775 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
353 |
227 |
$24K |
| D0274 |
Bitewings - four radiographic images |
791 |
777 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
820 |
802 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
277 |
153 |
$15K |
| D1351 |
Sealant - per tooth |
486 |
87 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
280 |
267 |
$12K |
| D0330 |
Panoramic radiographic image |
358 |
349 |
$11K |
| D9110 |
|
341 |
326 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
139 |
58 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,131 |
1,088 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
911 |
882 |
$7K |
| D2332 |
|
71 |
43 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
250 |
247 |
$5K |
| D1120 |
Prophylaxis - child |
55 |
54 |
$2K |
| D1330 |
|
90 |
90 |
$450.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$442.40 |
| D1310 |
|
88 |
88 |
$440.00 |
| D0601 |
|
20 |
20 |
$200.00 |