| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
3,273 |
1,232 |
$545K |
| D2750 |
|
318 |
242 |
$155K |
| D1110 |
Prophylaxis - adult |
1,638 |
1,612 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,181 |
1,153 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,473 |
2,436 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
528 |
299 |
$56K |
| D2332 |
|
331 |
164 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
276 |
158 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,165 |
1,158 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
769 |
735 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,205 |
1,182 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
181 |
90 |
$23K |
| D0330 |
Panoramic radiographic image |
314 |
309 |
$14K |
| D2335 |
|
62 |
38 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
846 |
806 |
$9K |
| D1120 |
Prophylaxis - child |
164 |
164 |
$7K |
| D2950 |
|
81 |
53 |
$7K |
| D4355 |
|
55 |
55 |
$6K |
| D3120 |
|
117 |
87 |
$4K |
| D4341 |
|
35 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
277 |
274 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$299.00 |
| D1330 |
|
26 |
26 |
$156.00 |