| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
615 |
331 |
$40K |
| D1120 |
Prophylaxis - child |
976 |
969 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
432 |
221 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
431 |
429 |
$15K |
| D0330 |
Panoramic radiographic image |
565 |
563 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
688 |
683 |
$13K |
| D1206 |
Topical application of fluoride varnish |
1,112 |
1,105 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
122 |
81 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
246 |
246 |
$10K |
| D1351 |
Sealant - per tooth |
389 |
117 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
131 |
68 |
$7K |
| D2330 |
|
91 |
43 |
$7K |
| D9430 |
|
243 |
240 |
$7K |
| D4341 |
|
87 |
27 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
164 |
163 |
$4K |
| D1110 |
Prophylaxis - adult |
128 |
128 |
$4K |
| D0274 |
Bitewings - four radiographic images |
214 |
212 |
$4K |
| D1352 |
|
176 |
51 |
$3K |
| D0272 |
Bitewings - two radiographic images |
146 |
144 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
129 |
128 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
361 |
217 |
$1K |
| D0350 |
|
85 |
38 |
$444.00 |
| D0270 |
|
30 |
28 |
$145.00 |