| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
550 |
311 |
$81K |
| D1351 |
Sealant - per tooth |
2,345 |
298 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
454 |
277 |
$54K |
| D1110 |
Prophylaxis - adult |
773 |
773 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,162 |
1,162 |
$32K |
| D1120 |
Prophylaxis - child |
565 |
564 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
976 |
974 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
619 |
619 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,467 |
819 |
$14K |
| D4341 |
|
84 |
27 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
276 |
276 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
131 |
131 |
$9K |
| D0274 |
Bitewings - four radiographic images |
240 |
240 |
$8K |
| D2394 |
|
47 |
34 |
$7K |
| D0272 |
Bitewings - two radiographic images |
202 |
202 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$2K |
| D2950 |
|
13 |
12 |
$2K |