| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,681 |
887 |
$193K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,476 |
741 |
$143K |
| D0330 |
Panoramic radiographic image |
1,958 |
1,758 |
$73K |
| D1110 |
Prophylaxis - adult |
1,981 |
1,825 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,745 |
1,532 |
$66K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
719 |
354 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,860 |
1,705 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,284 |
1,209 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
627 |
567 |
$20K |
| D2394 |
|
142 |
67 |
$19K |
| D4355 |
|
144 |
121 |
$8K |
| D1120 |
Prophylaxis - child |
189 |
154 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
313 |
271 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
178 |
88 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$396.12 |