| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,402 |
324 |
$78K |
| D1110 |
Prophylaxis - adult |
1,340 |
1,308 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
416 |
413 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,033 |
991 |
$12K |
| D1330 |
|
1,603 |
1,561 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,599 |
1,556 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
235 |
233 |
$2K |
| D0274 |
Bitewings - four radiographic images |
921 |
891 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,065 |
1,016 |
$780.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,035 |
982 |
$526.79 |
| D1120 |
Prophylaxis - child |
27 |
26 |
$0.00 |