| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
339 |
221 |
$52K |
| D1120 |
Prophylaxis - child |
883 |
883 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
276 |
185 |
$34K |
| D1351 |
Sealant - per tooth |
1,095 |
145 |
$33K |
| D1110 |
Prophylaxis - adult |
607 |
607 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,084 |
1,084 |
$29K |
| D2740 |
Crown - porcelain/ceramic |
38 |
28 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
269 |
269 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,180 |
1,105 |
$19K |
| D1206 |
Topical application of fluoride varnish |
740 |
740 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
385 |
385 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,241 |
768 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
436 |
436 |
$10K |
| D0274 |
Bitewings - four radiographic images |
188 |
188 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
130 |
129 |
$6K |
| D2394 |
|
31 |
27 |
$6K |
| D1354 |
|
99 |
22 |
$3K |
| D4355 |
|
12 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$325.00 |