| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,803 |
573 |
$305K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
869 |
399 |
$118K |
| D2335 |
|
351 |
129 |
$61K |
| D1110 |
Prophylaxis - adult |
541 |
536 |
$35K |
| D2332 |
|
166 |
87 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
343 |
339 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
327 |
303 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
57 |
$12K |
| D1206 |
Topical application of fluoride varnish |
392 |
392 |
$10K |
| D0274 |
Bitewings - four radiographic images |
405 |
400 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
653 |
612 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
312 |
300 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
92 |
$5K |
| D2394 |
|
25 |
17 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
373 |
360 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
140 |
140 |
$4K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$2K |
| D3120 |
|
46 |
29 |
$2K |
| D1330 |
|
12 |
12 |
$72.00 |