| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,456 |
730 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
1,903 |
1,893 |
$108K |
| D9430 |
|
2,968 |
2,148 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,205 |
1,195 |
$75K |
| D1120 |
Prophylaxis - child |
1,192 |
1,185 |
$46K |
| D0210 |
Intraoral - complete series of radiographic images |
946 |
939 |
$43K |
| D4341 |
|
527 |
141 |
$37K |
| D1110 |
Prophylaxis - adult |
447 |
438 |
$34K |
| D2394 |
|
358 |
230 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,324 |
2,313 |
$27K |
| D4910 |
|
327 |
327 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
337 |
175 |
$22K |
| D0274 |
Bitewings - four radiographic images |
976 |
974 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,193 |
1,643 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
358 |
334 |
$4K |
| D0240 |
|
371 |
176 |
$3K |
| D0350 |
|
670 |
189 |
$3K |
| D4342 |
|
38 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
143 |
137 |
$2K |